Patient Education and Counseling xxx (xxxx) xxx–xxx

Contents lists available at ScienceDirect

Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pec

Impact of beliefs about medication on the relationship between trust in

physician with medication adherence after stroke
Qianqian Fan a,b, Kinjal Doshi b, Kaavya Narasimhalu c, G. Shankari d, Pei Shieen Wong e,
⁎
Il Fan Tan f, Szu Chyi Ng g, Si Ying Goh c, Fung Peng Woon g, Deidre Anne De Silva c,
a
Zhengzhou University, School of Education, Zhengzhou, China
b
Singapore General Hospital, Department of Psychology, Singapore
c
National Neuroscience Institute (Singapore General Hospital Campus), Department of Neurology, Singapore
d
Duke-NUS Medical School, Singapore
e
Singapore General Hospital, Department of Pharmacy, Singapore
f
National Neuroscience Institute, Nursing Division, Singapore
g
Singapore General Hospital, Department of Neurology, Singapore

a r t i cl e i nfo a bstr ac t

Article history: Objective: To investigate the relationship between medication adherence, trust in physician and beliefs
Received 9 January 2021 about medication among stroke survivors. To determine whether beliefs about medication would mediate
Received in revised form 8 July 2021 the relationship between trust in physician and medication adherence.
Accepted 9 July 2021
Methods: A sample of 200 patients with a diagnosis of ischemic stroke or transient ischemic attack (TIA)
Available online xxxx
completed a one-time survey, including the shortened Medication Adherence Report Scale (MARS-5),
Beliefs about Medicines Questionnaire (BMQ), and Trust in Physician Scale (TIPS).
Keywords:
Medication Results: Our study found that medication adherence was associated with trust in physician (p = 0.019) and
Adherence four factors of beliefs about medication (BMQ1-Necessity: p < 0.001; BMQ2-Concerns: p = 0.024; BMQ3-
Secondary stroke prevention Overuse: p = 0.016; BMQ4-Harm: p < 0.001). Furthermore, we found monthly income of survivors mod­
Beliefs erated the relationship between trust in physician and medication adherence (p = 0.007, CI(95%): [−0.822,
Income −0.132]).
Conclusions: The beliefs about medication mediating the relationship between trust in physician and
medication adherence were different based on the stroke survivors’ income bracket.
Practice implications: Interventions being developed to improve medication adherence may benefit from
improving stroke survivors’ trust in physician and addressing their beliefs about medication. In addition,
healthcare providers are advised to take monthly income into consideration to effectively address stroke
survivors’ concerns regarding prescribed medications to mitigate stroke recurrence.
© 2021 Published by Elsevier B.V.

1. Introduction myocardial infarction and/or vascular death at four years post-stroke

Stroke survivors have a 15-fold increased risk of recurrent stroke
in the general population and those with more than one risk factor
have a further increased risk of recurrence [1]. Additionally, the risk
of secondary stroke accumulates with time and increases with each
stroke recurrence [2]. The collective risk of stroke recurrence in­
creases steadily over time from 1.8% at one month post-stroke onset
to 18.1% at four years, and a 41.3% composite risk of recurrent stroke,
⁎
Corresponding author at: National Neuroscience Institute (Singapore General
Hospital Campus), Department of Neurology, 20 College Road, Singapore 169856,
Singapore.
E-mail address: deidre.desilva@singhealth.com.sg (D.A. De Silva).
onset [3]. Hence, it is important to establish long-term adherence to
secondary stroke prevention strategies soon after initial stroke in­
cident [4].
Patients with ischemic stroke are generally prescribed at least an
antiplatelet agent, a cholesterol lowering agent, and an anti­
hypertensive agent to reduce the risk of recurrent stroke [5]. A
combination of these secondary prevention measures has been
postulated to reduce the risk of recurrent stroke by 20%–30% [6].
However, medication adherence is often low amongst stroke survi­
vors globally (33–50% non-adherent) [7,8], and even lower amongst
Asian stroke survivors, with non-adherence rates ranging from 34.7%
to 81.8% [9–11]. Among the factors associated with poorer medica­
tion adherence are younger age, and lower income bracket [12,13].

https://doi.org/10.1016/j.pec.2021.07.016
0738-3991/© 2021 Published by Elsevier B.V.

Please cite this article as: Q. Fan, K. Doshi, K. Narasimhalu et al., Impact of beliefs about medication on the relationship between trust in
physician with medication adherence after stroke, Patient Education and Counseling, https://doi.org/10.1016/j.pec.2021.07.016i
Q. Fan, K. Doshi, K. Narasimhalu et al. Patient Education and Counseling xxx (xxxx) xxx–xxx

Psychological factors such as beliefs about medication [8], have
been shown to affect medication adherence. Furthermore, patient’s
ability to trust their physicians has been shown to improve medi­
cation adherence by improving patient’s knowledge of the medica­
tion [14]. Trust in physician is defined as the degree to which
patients optimistically accept their medical condition and believe
that their physicians will care for their interests [15]. Previous re­
search has demonstrated that enhanced patients trust may improve
medication adherence effectively [16]. As the patient-physician re­
lationship and its impact on their beliefs about medication are po­
tentially modifiable factors of medication adherence [17],
understanding the relationship between these factors and their ef­
fects on adherence could potentially identify interventions that can
reduce the risk of stroke recurrence.
This study aims to understand the relationship between psy­
chological factors (trust in physician and beliefs about medication)
and their effects on medication adherence among stroke survivors.
We hypothesized that trust in physician and beliefs about medica­
tion will predict medication adherence; and that beliefs about
medication would mediate this relationship between trust in phy­
sician and medication adherence.
2. Methods
patients report more trust in physician in treating their medical
conditions [22].
2.3. Statistical analyses
We conducted mediation and moderation analyses with non-
parametric and re-sampling method bootstrapping [5000 re­
samples; 95% CI] [23], to better understand the relationship between
these psychological factors (trust in physician and belief about
medication) and their effects on medication adherence among
stroke survivors. Different from traditional methods, bootstrapping
made no assumption about the shape of the sampling distribution,
but allowed for irregularity of the sampling distribution. As a result,
bootstrapping approach could yield more accurate inferences com­
pared to traditional methods [23]. Specifically, we assessed (1) the
moderating role of demographic variables (gender, education, and
monthly income) on the relationship between trust in physician and
medication adherence, and (2) the significance of the indirect effect
proposed with mediational analysis between trust in physician and
medication adherence. All significance levels were set at p < 0.05.
All analyses were done with IBM SPSS Version 25 and the INDIRECT
PROCESS for SPSS (Version 3.4) was used for the mediation and
moderation analyses.

2.1. Participants 3. Results

The present study is an extension of a larger prospective cohort
study [11], of which ischemic stroke survivors attended their post-
stroke outpatient follow-up appointment at the Singapore General
Hospital (SGH) Clinic After Stroke Prevention Education Research
(CASPER) clinic from October 2018 to April 2019. Inclusion criteria
were ischemic stroke or transient ischemic attack (TIA) patients
aged 21 years old and above who were able to provide informed
consent. Those who were non-residents of Singapore were excluded
from the study.
Of 327 eligible patients approached, 127 (38.8%) declined parti­
cipation. The three most common reasons for declining participation
were lack of interest (37.0%), lack of time (19.7%) and not feeling well
(3.9%). The final sample consisted of 200 stroke survivors.
Characteristics of participants were reported in Results.
2.2. Measurements
3.1. Participant characteristics and correlations between study
variables
Amongst the 200 patients who consented (mean age: 62.91 (SD =
1.88); male 63.5%), 171 (85.5%) patients had a diagnosis of ischaemic
stroke; the remaining 29 (14.5%) had a diagnosis of TIA. Ethnically,
80% of patients were Chinese, 9.0% were Indian, 7.5% were Malay,
with the remaining 3.5% identifying as of other ethnic groups.
Means and standard deviations of demographics and study
measures are presented in Table 1. Pearson correlations between the
study measures are presented in Table 2. As hypothesized, medica­
tion adherence was correlated to trust in physician (p = 0.019), the
four factors of beliefs about medication (BMQ1-Necessity:
p < 0.001; BMQ2-Concerns: p = 0.024; BMQ3-Overuse: p = 0.016;
BMQ4-Harm: p < 0.001). Trust in physician was also correlated to
four factors of beliefs about medication (p < 0.001).

All patients completed a one-time survey that spanned 3.2. Mediation and moderation analyses
15–20 min, which was administered by trained coordinators in their
language of choice (English, Mandarin, Tamil or Malay). In bias-corrected bootstrapped analyses, we found that gender
Demographics information were collected, including: gender, age, and education did not moderate the relationship between trust in
race, education level, and monthly income. physician and medication adherence (as evidenced by a confidence
The shortened Medication Adherence Report Scale (MARS-5) is a
5-item scale revised from the original 10-item MARS by Thompson Table 1
Characteristics of patients.
et al. to measure medication adherence [18,19]. Medication ad­
herence is defined as the extent to which patients take their pre­ Mean (N) SD (%)
scribed medications as recommended by the prescribing medical Age 62.910 11.878
doctor and was treated as a continuous variable [20]. Gender (Male) 127 (N) 63.5 (%)
Beliefs about Medicines Questionnaire (BMQ) [21], is an 18-item Ethnicity
Chinese 160 (N) 80.0 (%)
validated measure that is commonly used to quantify the four types
Indian 18 (N) 9.0 (%)
of beliefs and concerns that patients may have about their medica­ Malay 15 (N) 7.5 (%)
tion: i) BMQ1-Necessity (5 items); ii) BMQ2-Concerns (5 items); iii) Others 7 (N) 3.5 (%)
BMQ3-Overuse (4 items); iv) BMQ4-Harm (4 items). The specific Education
No formal education 7 (N) 3.5 (%)
necessity and concerns subscales deal with secondary stroke pre­
Primary 42 (N) 21.0 (%)
vention medications while the general overuse and general harm Secondary 82 (N) 41.0 (%)
subscales look at the patients’ perception of medication use as a Tertiary and above 69 (N) 34 (%)
whole. Monthly Income
Trust in Physician Scale (TIPS) is a point scale that quantifies < S$2000 96 (N) 46.5 (%)
≥S$2000 114 (N) 53.5 (%)
patients’ trust in their physicians, with higher score indicating

2
Q. Fan, K. Doshi, K. Narasimhalu et al. Patient Education and Counseling xxx (xxxx) xxx–xxx

Table 2 4. Discussion and conclusion

Means (M), standard deviations (SD), and correlations between study measures.

MARS TIPS BMQ1 BMQ2 BMQ3 BMQ4 4.1. Discussion

Necessity Concerns Overuse Harm

MARS _ 0.172* 0.273*** −0.160* −0.171* −0.335*** Our present study is a novel approach demonstrating that trust in
TIPS _ 0.324*** −0.246*** −0.318*** −0.326*** physician and beliefs about medication influence medication ad­
BMQ1 _ −0.120 −0.210** −0.399*** herence among stroke survivors; the direction of influence being
BMQ2 _ 0.282*** 0.246***
determined by the type of beliefs they have about the medication.
BMQ3 _ 0.503***
BMQ4 _ Further, we discovered that monthly income moderated the re­
M 4.732 3.674 3.390 2.814 2.811 2.591 lationship between trust in physician and medication adherence.
SD 0.513 0.417 0.681 1.573 0.671 0.672 Follow-up mediation analyses indicated that beliefs about medica­
Note: TIPS = Trust in Physician Scale; BMQ = Belief in Medicines Questionnaire; tion mediated the relationship between trust in physician and
MARS = Medication Adherence Report Scale. medication adherence among stroke survivors, but the effects were
*
p < 0.05, different by income levels.
**
p < 0.01,
*** The mediation model showed that trust in physician could affect
p < 0.001.
how patients perceive medication, which in turn impacts medica­
tion adherence. The result was consistent with previous research
that more trust led to higher adherence to medical treatment [24].
To foster trust among patients for their physicians, clinicians need to
develop their communication skills to be perceived as more sup­
portive and participatory [25], and be personally involved in their
care of the patient [26]. These factors, together with an emphasis on
patient education [27], have been found to improve patient’s trust
towards their physician. As such, post-stroke management programs
can integrate these suggestions to enhance the delivery of patient
Fig. 1. The structural model of trust in physician predicting medication adherence,
moderated by monthly income. Note: TIPS = Trust in Physician Scale; BMQ = Belief in
care in order to promote better clinical outcomes for stroke sur­
Medicines Questionnaire; MARS = Medication Adherence Report Scale. vivors.
Consistent with previous studies, we found that stroke survivors
interval including zero) (gender: β = 0.235, p = 0.190, CI(95%): [−0.117, from the higher monthly income bracket were more likely to adhere
0.586]; education: β = 0.228, p = 0.195, CI(95%): [−0.118, 0.575]). We to their medication when they have trust in their physicians [28].
found that monthly income modified the relationship between trust This association may be explained by the fact that trust in physician
in physician and medication adherence (β = −0.477, p = 0.007, CI(95%): is facilitated by patient’s health literacy; patient who report higher
[−0.822, −0.132]); there was an association between trust in physi­ income are more likely to be health literate [29,30]. Health literacy
cian and medication adherence among those in the higher income has been shown to improve health-related knowledge and skills,
bracket (β = 0.386, p < 0.001, CI(95%): [0.176, 0.596]), while those with which encourages health-promoting behaviours [31]. Research
lower income had no association (β = −0.091, p = 0.512, CI(95%): highlights that patients from the high income bracket are more
[−0.365, 0.183]). Subsequent mediation analyses were conducted likely to seek and rely on their physician for health information [32].
across different levels of monthly income. (Fig. 1). Also highlighted by our study, patients’ evaluations of prescribed
Results of the bootstrapping analysis of the model (Fig. 2) in­ medication are mostly affected by their perceptions of personal need
vestigating the mediating effect of the four factors of beliefs about for treatment and concerns about potential adverse consequences
medication for two levels of monthly income groups are shown in [33]. Further, depending on their income, different beliefs impact
Table 3. For stroke survivors with a higher monthly income, the stroke survivors’ adherence to medication, which again, may be a
relationship between trust in physician and medication adherence reflection of their health literacy. Medication adherence among
was significantly accounted for by three factors of beliefs about stroke survivors who report a lower monthly income was primarily
medication: the belief regarding the necessity of specific medication affected by their beliefs that medications in general are harmful and
(BMQ1-Necessity), the belief regarding the concerns of specific should not be taken continuously. For stroke survivors from the
medication (BMQ2-Concerns), and the belief that medication in lower income bracket, aside from cost of medication, they may have
general is harmful (BMQ4-Harm). Among those with a lower limited resources to be knowledgeable of the purpose and instruc­
monthly income, only the fourth belief regarding the general harm tions to follow prescribed medication [34].
of medication (BMQ4-Harm) significantly mediated effect of trust in One belief that impacts medication adherence and is shared
physician on medication adherence. among stroke survivors, regardless of their income, is belief that
medications are harmful and should not be taken continuously.
Previous studies have shown that patients are more likely to default
medications that do not provide symptomatic relief, such as those
that are used for secondary stroke prevention. Furthermore, some of
these medications have potential side effects that negatively impact
their perception of the medication and its benefits. Without tangible
symptom relief and with possible side effects, it is not surprising
that survivors may default medication [35]. This belief in general
harm of medication may prohibit them from adhering to medication
and previous studies suggest that they consciously do not follow
physicians’ prescriptions [36].
While, the present study found that survivors’ belief that medi­
Fig. 2. The structural model of trust in physician and belief about medication pre­
cations are overused by medical doctors to be significantly corre­
dicting medication adherence. Note: TIPS = Trust in Physician Scale; BMQ = Belief in lated with medication adherence, it was not a mediating factor in
Medicines Questionnaire; MARS = Medication Adherence Report Scale. the relationship between trust in physician and medication

3
Q. Fan, K. Doshi, K. Narasimhalu et al.
Table 3
Results of mediating effect of BMQ.
Higher income
Indirect Effect
BMQ1-Necessity 0.139*
BMQ2-Concerns 0.038*
BMQ3-Overuse 0.084
BMQ4-Harm 0.156*
Note: BMQ = Belief in Medicines Questionnaire; CI = confidence interval.
*
significant mediating effect based on 95% confidence interval
adherence. We postulate that stroke survivors are susceptible to
polypharmacy [37], and often see multiple physicians. Trust in one
physician alone does not determine their adherence to specific
medication. Rather, given patients’ concern over medication overuse
[38], they are more likely to not adhere to prescribed medication
especially if they perceive it negatively impacts them. Hence, we
would also recommend to enhance interprofessional communica­
tions between primary care providers, specialists, and pharmacists
who well-positioned to identify medication non-adherent behaviour
as part of the medication review process to better coordinate med­
ications from different resources [39].
To generalize the results and conclusions of the present study,
limitations need to be taken into consideration. First, the present
study employed self-reported measures, especially, assessment of
medication adherence, in the relatively early period after stroke. In
addition, research has shown that patient’ medication adherence
rates declined over time [40]. Therefore, future researchers could
collect objective data of medication adherence in a longitudinal
study to re-examine models found in the present study. Secondly,
this heterogeneous sample consisted of patients with stroke or TIA.
The present study did not examine mechanisms of medication ad­
herence among patients with one diagnosis - stroke or TIA, due to
small number of patients with TIA.
4.2. Conclusion
This study is the first to emphasize the importance of fostering
trust in the physician among stroke survivors given its influence on
their beliefs regarding medication prescribed as secondary stroke
prevention measures, and consequently its impact on survivors’
adherence to these medication. This relationship may be further
evaluated by examining interventions designed to improve the re­
lationship between the stroke survivor and the inter-professional
stroke team managing their care. Future studies may also encounter
other modifiable factors by assessing the processes that account for
the influence of trust in physician and survivors’ beliefs about
medication on medication adherence such as health literacy.
4.3. Practice implications
Findings from this study will encourage the development of in­
terventions targeted in building trust in physician and addressing
beliefs about medication. Further, it is important to consider the
income bracket of the audience developing and delivering inter­
vention programs for improving medication adherence. Specially,
stroke survivors with higher income would benefit from programs
emphasizing their beliefs on the necessity to take medication, while
stroke survivors from the lower income bracket would benefit from
increasing patient literacy regarding medications in general. It is also
important to ensure that such information is consistently delivered
across the various healthcare professions that are supporting the
stroke survivors’ journey to recovery.
Patient Education and Counseling xxx (xxxx) xxx–xxx
Lower income
CI(95%) Indirect Effect CI(95%)
[0.002, 0.327] 0.052 [−0.002, 0.134]
[0.007, 0.229] 0.033 [−0.009, 0.099]
[−0.014, 0.217] 0.014 [−0.009, 0.058]
[0.007, 0.364] 0.082* [0.025, 0.183]
CRediT authorship contribution statement
Qianqian Fan: Conceptualization, Methodology, Formal analysis,
Writing – original draft, Writing – review & editing. Kinjal Doshi:
Conceptualization, Methodology, Writing – original draft, Writing –
review & editing, Supervision. Kaavya Narasimhalu:
Conceptualization, Writing – review & editing. G. Shankari:
Conceptualization, Investigation, Writing – review & editing. Pei
Shieen Wong: Conceptualization, Writing – review & editing. Il Fan
Tan: Conceptualization, Writing – review & editing. Szu Chyi Ng:
Investigation, Project administration. Si Ying Goh: Investigation.
Fung Peng Woon: Investigation. Deidre Anne De Silva:
Conceptualization, Methodology, Writing – review & editing,
Supervision.
Funding
The study was supported by the AM-ETHOS Duke-NUS Medical
Student Fellowship, Singapore (AM-ETHOS01/FY2018/14-A14). The
funding source had no involvement in the study design; the col­
lection, analysis, and interpretation of data; the writing of the re­
port; and the decision to submit the article for publication.
Ethics approval
This study was conducted with the approval of SingHealth
Centralised Institutional Review Board (CIRB No. 2018/2911).
Declaration of Competing Interest
The authors declare that they have no known competing fi-
nancial interests or personal relationships that could have appeared
to influence the work reported in this paper.
Acknowledgements
We would like to thank clinical research coordinator Mr. Aeden
Kuek Zi Cheng for his help with literature review.
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