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Evaluation & Synthesis of Evidence Paper

Evaluation & Synthesis of Evidence Paper

Problem Statement

Diabetes has reached alarming levels worldwide, with millions of people suffering from

this chronic disease. By 2030, diabetes is predicted to affect 10.2% of the global population,

equivalent to 578 million individuals , and is expected to surge even further, reaching 783

million individuals by 2045 (Magliano et al., 2021). Saudi Arabia ranked among the top five

countries in the Middle East and North Africa (MENA) region, reporting 4.3 million cases of
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diabetes among individuals aged 20 to 79 years in 2021 (Magliano et al., 2021). This underscores

the urgency of addressing factors that impede effective diabetes management, with medication

adherence playing a crucial role.

Adhering to medication is a significant factor influencing the outcomes of patients with

chronic diseases. In the case of diabetes, adherence to recommended medications reduces the

likelihood of hospitalization, reduces the cost of healthcare, reduces the risk of diabetes

complications, and decreases mortality rates (Kirkman et al., 2015). The estimated rates of

adherence to diabetes medications exhibit significant variability, depending on factors such as

the studied population as well as the criteria used to measure adherence. One review found that

the prevalence of adherence ranged from 38.5 to 93.1% and continues to be a major problem that

significantly contributes to poor glycemic control in diabetic patients (Krass et al., 2015).

The scope of the problem is underscored by the need to comprehensively assess the levels

of treatment adherence among diabetes mellitus patients in Saudi Arabia. Identifying the factors

that impact medication adherence in this specific population is imperative in order to tailor

interventions and improve health outcomes. The population statistics reveal the gravity of the

issue, as a considerable proportion of individuals with diabetes may not be adhering to their

prescribed treatment plans. Consequently, nonadherence can result in inadequate glycemic

control, increased complications, and a greater burden on the healthcare system (Polonsky &

Henry, 2016).

Addressing medication adherence among diabetes patients in Saudi Arabia goes beyond

individual health outcomes, extending to improving care, reducing healthcare costs, and

advancing scientific knowledge about patient behavior and treatment adherence. Therefore,
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understanding factors influencing treatment adherence is crucial for developing strategies to

improve outcomes and advance medical practices in diabetes management.

The purpose of this paper is to conduct a critical analysis of four studies exploring factors

influencing medication adherence among diabetic patients in Saudi Arabia in order to identify

and address gaps in existing literature that might need further investigation.

Evaluation of the Reviewed Articles

Four studies addressed the factors influencing medication adherence among diabetic

patients, sharing a common geographical focus on Saudi Arabia (Alqarni et al., 2018; AlQarni et

al., 2019; Alshehri et al., 2020; De Villiers & Alhalabi, 2015). De Villiers & Alhalabi (2015)

included 1,409 participants with type 2 diabetes mellitus (T2DM) from five ambulatory care

clinics in the Western Region, with a mean age of 55 ±11.06, comprising 48% males and 52%

females. Alqarni et al. (2018) focused on 375 Saudi nationals from six sectors of Bisha Health

Affairs, aged 18–40 years (21.1%), 41–59 years (43.2%), and ≥60 years (35.7%), with 52.3%

males and 47.7% females; the sample included 76.5% rural residents, 36.3% uneducated

individuals, and a mix of Type 1(20%), and Type 2 diabetes cases (80%). Alshehri et al. (2020)

examined 387 T2DM patients in Al Iskan, Al Waha, and Bahrah Primary Health Care Centers,

NGHA, Jeddah, with a mean age of 54 ±11 years, consisting of 69.5% males and 30.5% females,

with 89.9% being educated. AlQarni et al. (2019) studied 212 patients, from out-patients in

Khobar City, predominantly male (67%) and one-third female (33%), with a mean age of 44.17

±15.6 years, and 46.2% had education up to the graduation level. These studies encompassed

various demographics and healthcare settings in Saudi Arabia.

In terms of study design, three studies were descriptive analysis cross-sectional study

(Alqarni et al., 2018; AlQarni et al., 2019; De Villiers & Alhalabi, 2015). One study was
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descriptive cross-sectional study (Alshehri et al., 2020). Regarding the theoretical frameworks,

three studies did not explicitly mention a specific theoretical framework guiding their research

(Alqarni et al., 2018; AlQarni et al., 2019; Alshehri et al., 2020) .In contrast, one study utilized

the Health Belief Model to explore treatment adherence among type II diabetes patients (De

Villiers & Alhalabi, 2015). Regarding the sampling, it is noteworthy that all the studies employed

a convenience sampling approach. The measurement tools employed also demonstrated diversity.

One study used the Morisky Green Levine Medication Adherence Scale (MGLS) for assessing

medication adherence(Alqarni et al., 2018). Also, another study used the General Medication

Adherence Scale (GMAS) with demonstrated reliability through Cronbach's alpha= 0.816

(AlQarni et al., 2019). In contrast, two studies relied on a structured self-report questionnaire

(Alshehri et al., 2020 ; De Villiers & Alhalabi, 2015).

Critical Analysis and Synthesis

Strengths

problem statement and purpose

The studies demonstrate notable strength in their precise articulation of both problem

statements and purposes. The well-defined problem and purpose statements enhance the overall

coherence and relevance of the studies, enabling a more focused and impactful exploration of

medication adherence dynamics in diabetic patient populations.

Cross-Sectional Study Design Suitability

All selected studies utilized cross-sectional descriptive or analysis designs to investigate

medication adherence among diabetic patients in Saudi Arabia (Alqarni et al., 2018; AlQarni et

al., 2019; Alshehri et al., 2020; De Villiers & Alhalabi, 2015) . This methodological choice aligns

with the overarching research goals of capturing a momentary snapshot of adherence levels as
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well as identifying factors associated with adherence. A variety of aspects of medication

adherence are explored using this design, including sociodemographic factors, clinical variables,

and patient behaviors. Therefore, cross-sectional designs are strong in providing a

comprehensive overview of medication adherence patterns and associated variables at a specified

point in time without the need for long-term follow-up (Wang & Cheng, 2020).

Diversity in Study Samples

The studies include diverse demographic characteristics, such as gender, age, residence,

educational background, marital status, occupation, and family income, contributes to the

strength of the literature. Having this diversity allows us to explore how various

sociodemographic factors may impact medication adherence in a more nuanced way.

Utilization of Established Scales

Using established scales like the Morisky Green Levine Medication Adherence Scale

(MGLS) and the General Medication Adherence Scale (GMAS) are noteworthy strengths

(Alqarni et al., 2018; AlQarni et al., 2019). These scales have been widely validated and used in

diverse healthcare settings, contributing to the reliability and validity of the reported adherence

measures. Using standardized tools facilitates comparisons and analyses across different research

initiatives because it ensures that the studies adhere to established methodologies (Lamm et al.,

2020)

Weaknesses and Gaps

Lack of Theoretical Frameworks

In most studies, explicit theoretical frameworks were absent, which constitutes a

significant weakness. The Health Belief Model, utilized in one study (De Villiers & Alhalabi,

2015), offers a structured approach to understanding health-related behaviors. Incorporating

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theoretical frameworks into research can provide a more comprehensive understanding of the

intricate factors that influence medication adherence (Peh et al., 2021). Therefore, future studies

should prioritize the integration of theoretical perspectives in their research.

Cross-Sectional Designs

While the cross-sectional study designs employed in the selected investigations provide

valuable insight into medication adherence among diabetics at specific points in time, they come

with inherent weaknesses. In cross-sectional studies, causal relationships cannot be established

because the snapshot does not capture the temporal evolution of variables. Furthermore, these

designs might not capture the complexity of adherence patterns over time, making it impossible

to distinguish causal pathways and changes in behavior over time. It may be possible to enhance

the study design by incorporating more robust study designs, such as longitudinal approaches,

which can provide a deeper analysis of medication adherence over time, including identifying

trends and causal relationships. This could provide an in-depth understanding of adherence

behaviors among diabetic patients in Saudi Arabia.

Self-Report

The reliance on self-report measures is a weakness across all studies, which introduces

bias. The participants were asked to recall and report their medication adherence behaviors

through self-completed questionnaires or scales. Several biases can be introduced by this

method, such as recall bias, social desirability bias, and subjective interpretation. There is a

possibility that self-reported data might be subject to recall bias because participants may have

trouble accurately remembering and reporting their medication adherence behaviors, especially

for routine tasks. It is possible to overestimate adherence levels due to faulty memory, which

could compromise the validity of the reported adherence levels. Furthermore, self-reported
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measures are subject to social desirability bias, where respondents may provide answers that

align with society's expectations. Participants may present themselves as more positive to

healthcare providers in health-related behaviors like medication adherence, potentially inflating

reported adherence levels.

Selection bias

A notable weakness across the studies is the participant selection. While one study

employed a computer-generated random selection (AlQarni et al., 2019), others relied on

convenience sampling during health center attendance or outpatient clinic visits. Selection bias

might have occurred since participants who attend healthcare centers typically care more about

their health which affects the generalizability of the findings. Also, the skewed gender

distribution, marked by a significant male majority in 50 % of the studies, could potentially

hinder the generalizability of their findings (AlQarni et al., 2019; Alshehri et al., 2020).

There is a lack of clarity in describing the sampling strategies across studies, resulting in

concerns about selection bias, ultimately influencing generalizability. Therefore, it is important

for future studies to provide comprehensive information about their sampling strategies in order

to enhance their transparency and generalizability.

Response rate

There is no information about the response rate in the studies, which raises questions

about their reliability and generalizability. It is imperative to understand the response rate when

assessing the external validity and representativeness of the sample. Having a low response rate

may introduce selection bias, affecting the study's ability to draw accurate conclusions about the

wider population. Furthermore, it may raise questions about internal validity, since non-

responders might have different characteristics. Consequently, reporting response rates is

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essential for ensuring the credibility of research findings as well as their applicability to a wider

population.

Instrumentation

It is important to note that the four studies employed various tools to measure medication

adherence, like the MGLS, GMAS, and structured self-report questionnaires. While the MGLS

and GMAS are respected for their validity, the absence of reliability and validity assessments for

the questionnaires in 50% of the studies raises concerns about their quality and accuracy. This

lack of information on reliability and validity might impact accuracy and consistency. Also, the

use of different instruments across studies could hinder comparisons and generalizability. A lack

of standardized conceptual definitions of medication adherence in diabetic patients is evident in

the diverse instruments used across the studies. Establishing standardized conceptual definitions

for medication adherence in diabetic patients in future research can enhance consistency and

comparability in measurements.

Generalizability

Across these studies, there are overarching weaknesses that limit their generalizability.

Collectively, the studies face significant challenges in terms of external validity, limiting their

ability to generalize to broader populations and contexts. The geographic specificity of the

studies is one significant limitation since all studies concentrate on specific regions in Saudi

Arabia. Considering localized settings raises concerns about the findings applicability to people

from various cultural backgrounds, with varying healthcare systems, and accessing healthcare

services.

Implications for Nursing Practice

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The absence of intervention studies targeting medication adherence among diabetic

patients in Saudi Arabia is a notable gap in the literature. A gap like this impedes the

development of tailored, evidence-based interventions for nursing practice, hindering its

advancement. Performing such studies could fill this critical gap and help healthcare

professionals improve patient outcomes and diabetes management by providing insights into

effective strategies for improving medication adherence. Addressing this gap is vital for

influencing nursing practice in Saudi Arabia, enabling nurses to proactively plan and implement

personalized care, ultimately improving patient outcomes.

Also, another notable gap in the literature is the limited exploration of how personal and

cultural beliefs influence medication adherence among Saudi diabetic patients. Despite existing

studies focusing on sociodemographic and clinical factors, the influence of cultural beliefs on

adherence remains understudied. Identifying and addressing this gap will enhance adherence

outcomes by tailoring nursing interventions to patients' cultural contexts. By tailoring

communication and support strategies to align with cultural values, nurses may be able to foster

better relationships and potentially improve medication adherence and diabetes management

outcomes in the Saudi Arabian population.

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Review of Literature Worksheet/Table

Author Problem & Theoretical Key Concepts Study Sample Measures Key Study Methodological problems: Threats to
/Date Purpose Framework &Variables Type &  Who (reliability, Findings (include Study Validity
(if one used) Design  Size validity) p-values for
Interventi  Strategy significant (Critical Analysis)
on (Y or findings)
N)
(Alqarni Clear problem Not Dependent Descriptive Who: Morisky Green Occupational status Internal Validity Concern:
et al., statement: mentioned. variable analysis Saudi Levine was significantly Selection: convenience sample.
2018) diabetes is adherence to Cross- nationals, age Medication associated with a Also, does not explicitly mention the
rising globally diabetic sectional groups: 18– Adherence high level of selection process as being random or non-
and specifically medications study. 40 years Scale (MGLS). adherence random. However, it does mention that the
in Saudi Arabia, was based on (21.1%), 41– patients had (P=0.037). participants were recruited from primary
posing patients’ self- 59 years high (MGLS Current medication health care centers in the Bisha.
significant reported recall (43.2%), ≥60 score 0), (P<0.001). Those who attend primary health care
health and of using The study years intermediate centers tend to care more about their
economic diabetic did not (35.7%). (MGLS score Sociodemographic health, so selection bias could have been
problems. The medications involve any Gender: 1 or 2), and Factors: not an issue.
non-adherence over the interventio 52.3% males, low adherence significant.
to diabetes previous 2 n. 47.7% (MGLS score Self-report bias: Patient adherence can be
medications weeks using females. ≥3) Association overestimated by using a self-report
contributes to MGLS. Rural between level of method. The adherence data were based on
complications residents: Validity: The adherence and A1c participants' recall, which may not
and increased Independent 76.5%, MGLS is p<0.001, A1c <7 accurately reflect their actual medication-
healthcare variables Uneducated: highlighted in were more likely to taking behaviors.
costs. sociodemograp 36.3%. this research as have high
Purpose: hic Type 1 the most adherence. Instrumentation reliability not mentioned.
clearly stated: characteristics diabetes: widely used Association
the study aims (nationality, 20%, Type 2 scale for between level of External Validity Concern:
to assess gender, age, diabetes: research and adherence and Generalizability to other populations: The
medication residence, 80%. has been associated study was conducted among patients with
adherence and marital status, From six validated comorbidities: diabetes in the Bisha governorate of Saudi
identify factors education sectors of across a broad p<0.001 Arabia. The findings may not be
associated with level, and Bisha Health range of respondents with generalizable to populations in other
non-adherence occupational Affairs. diseases, no associated regions or countries with different
among diabetes status) and including for comorbidities were healthcare systems, cultural backgrounds,
patients in clinical profile Size: 375 patients with considered to have and access to healthcare.
primary (disease type, participants. low literacy, a high level of
healthcare disease Strategy: Not and the adherence.
centers in Bisha duration, explicitly sensitivity and
province. current mentioned. specificity are
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medications, However, it over 70%.

recent A1c does mention
result, and that the Reliability not
other participants mentioned.
comorbidities were
if present). recruited
from primary
Key concept: health care
factors centers in the
associated Bisha
with adherence
to diabetic
medications
and its
association
with glycemic
control (A1c
levels) and
comorbidities
among
diabetic
patients.
(Alshehr Clear problem The article Dependent Descriptive Who: T2DM The study used 68.5% reported
i et al., statement: does not variable is Cross- patients, a self- adherence to their Internal Validity Concern:
2020) Incidence of explicitly adherence to sectional mean age 54 completed medications, while The sample size was calculated using Rao
diabetes is mention a diabetes study. ± 11 years, questionnaire 31.5% were Online Software.
growing specific medications, 69.5% males, to collect data. nonadherent. The
globally, and theoretical as it is being 30.5% The reliability most common Measurement Bias: The instrument lacks
poor adherence framework. assessed The study females. and validity of reason reported validity and reliability. The study does not
to T2DM through the 20 did not Employment: the was forgetting to explicitly mention the validity and
treatment can yes or no involve any 51.93% questionnaire take their reliability of the questionnaire used to
result in severe questions in interventio employed, were not medication (n=82; assess medication adherence.
medical the n. 34.62% explicitly 67.21%). Another
conditions such questionnaire. retired, mentioned in major reason for Selection bias: convenience sample
as gangrene, 13.43% not the article. nonadherence to Also, not provide information about the
nephropathy, Independent employed. In T2DM treatment selection prosses for the participants. It
retinopathy, variables Primary was fatigue with only mentions that the participants were
neuropathy, and Age (years) Health Care taking medications randomly selected in the study area at the
heart disease. Gender Centers, for a long time time of data collection. The article does not
(male/female), National (n=61, 50%). provide details on how the random
Purpose Nationality, Guard Health However, the study selection was conducted.
clearly stated: Marital status, Affairs, does not provide
To assess the Education, and Jeddah, Saudi specific p-values Self-report Bias: the use of a questionnaire
adherence to Occupation. Arabia for these findings, with yes or no questions to assess
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treatment Profile of making it difficult adherence to diabetes medications. This

among type 2 diabetes to determine the introduces the potential for self-report bias.
DM patients at mellitus: Size: The statistical
Jeddah's duration of sample size significance of the No information about the response rate
NGHA, in order diabetes was 387 results.
to identify mellitus, age at External Validity Concern:
obstacles and onset, family Strategy: The The sample was selected from specific
factors that will history of participants primary healthcare centers in Jeddah,
enhance diabetes were Saudi Arabia, which may not be
compliance.. (yes/no), randomly representative of the entire population of
taking the selected in T2DM patients in the country.
antidiabetic the study area
drugs as at the time of
advised by data Most of the sample were males. 269 males
your doctor? collection. (69.5%) and 118 females (30.5%).
(yes/no)

The key
concepts
patient-related
factors that
influence
medication
adherence
(De Clear problem The study Dependent Descriptive Who: T2DM The data Female and >5
Villiers statement: utilized the Variable: correlation patients, collection years diagnosed Internal Validity Concern:
& Uncontrolled Health Treatment cross- mean age 55 method significantly more ✓The data analysis was meticulously
Alhalabi diabetes Belief Adherence sectional ± 11.06 years, involved a likely for detailed. The minimum sample size was
, 2015) mellitus (DM) Model as its (Medication study 48% males, structured self- medication calculated.
persists among theoretical adherence and 52% females. report adherence
diabetics in framework. lifestyle The study Education: questionnaire (p=<0.001).
Jeddah despite adherence). did not 50% no completed by Self-report: the study relies on self-report
intensive health involve any schooling, the Participants with questionnaires, which may be subject to
education Independent interventio 38% partial participants. no schooling most biases such as social desirability bias or
efforts, with Variables: n. schooling, medication recall bias. This could affect the accuracy
little gender, level 12% high The reliability adherent of the reported treatment adherence levels.
understanding of education, school and of the (F(2)=8.34;
of factors and age, above. questionnaire p=<0.001). Response rate: no information about the
affecting duration of not explicitly response rate in the studies, which raises
adherence, diagnoses Size: The mentioned in Medication questions about their reliability and
leading to a ,Hb1Ac, BMI, sample the article. adherent generalizability.
need for further complications, comprised participants more
research. medications. 1,409 likely to have BMI Selection: convenience sample.
Perceptions of ≥25 (p=0.007). Also, the sampling strategy is not clearly
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Clear purpose: severity, risk, Strategy: The described. This could introduce selection
This study aims benefits, and participants Males significantly bias and limit the generalizability of the
to assess the Barriers. were more likely for findings. The article does not provide
levels of Intrapersonal randomly lifestyle adherence details on how the random selection was
treatment and health care selected from (p=<0.001). conducted.
adherence provider five
among type II factors and ambulatory Partial schooling Measurement Bias: The instrument lacks
diabetics, cues to action. care clinics linked to validity and reliability; the questionnaire
utilizing the affiliated with significantly better adapted from a prior study.
Health Belief Key concept the Ministry lifestyle adherence
Model to investigate the of National than no schooling The study does not provide explicit
identify factors factors Guard in the and high school information on reliability.
influencing influencing Western certificate (p <
adherence. treatment Region. 0.001, F(2)=14.90). External Validity Concerns:
adherence
among Generalizability: The study was conducted
diabetes in the Western Region of Saudi Arabia, and
mellitus type II the findings may not be applicable to other
patients in regions or countries with different cultural,
Saudi Arabia social, and healthcare contexts.
and their
relationship
with glycemic
control and
weight
management.
(AlQarn Clear problem The study Dependent Descriptive Who: Saudi The General No significant Internal Validity Concern:
i et al., and purpose did not Variable: analysis out-patients Medication gender association - Instrumentation: not a problem.
2019) statements: the explicitly Medication cross- with type 2 Adherence with adherence
study highlights mention a adherence sectional DM.67% Scale (GMAS) scores (p > 0.05), ✓ The sample size was calculated to be
the issue of specific assessed study. males, 33% used in the except for cost- 178 participants.
medication non- theoretical through the females, study which is related non-
adherence framework. GMAS. mean age subcategorized adherence (p <
among Saudi The study 44.17 ± 15.6 into three 0.01, χ2 = 20.84); Selection: convenience sample;
patients with Independent did not years. subscales: most males showed patients enrolled at the hospital who had
type II diabetes. Variables: involve any Marital patient slightly better appointments in the out-patient endocrine
Demographic interventio status: 73.6% behavior adherence than clinics were selected randomly by help of a
This study aims factors n. married, related non- females. computer-generated list from hospital’s
to document (gender, age, Education: adherence database.
adherence marital status, 46.2% up to (PBNA), HbA1c showed a
patterns and lay education, graduation additional significantly
the foundation income), level. disease and moderate-to-strong Self-report: The study relied on self-
for future health-related pill burden negative reported data, which may be subject to
investigations information Size: 212 related non- correlation with recall bias or social desirability bias.
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into the (comorbidity, patients adherence PBNA score (ρ = –

behavior of insurance, (ADPB), and 0.326, p < 0.01). Response rate: no information about the
patients HbA1c). Strategy: The cost-related Glycated response rate in the studies, which raises
regarding participants non-adherence hemoglobin had a questions about their reliability and
medication Key Concept: were (CRNA). significantly generalizability.
adherence. Exploring randomly moderate negative
factors selected from Is a valid tool correlation with External Validity Concern:
influencing the out- to measure ADPB score (ρ = – The study was conducted in Khobar City,
adherence to patient medication 0.231, p < 0.01) Saudi Arabia, and the findings may not be
diabetes endocrine and adherence in and a moderate-to- generalizable to other regions or countries.
medications diabetic patients with strong negative
using GMAS clinics at chronic. correlation with The study focused on patients with type II
and King Fahd CRNA score (ρ = – diabetes who takes oral medications, and
demographic/h University The reliability 0.273, p < 0.01). the findings may not be applicable to
ealth-related Hospital in of GMAS was patients with other types of diabetics or on
variables. Khobar City. Cronbach insulin.
alpha (α) =
0.816 Most of the sample were males (N = 142,
67%) and a third were females (N = 70,
33%).
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References

Alqarni, A. M., Alrahbeni, T., Qarni, A. A., & Qarni, H. M. A. (2018). Adherence to diabetes

medication among diabetic patients in the Bisha governorate of Saudi Arabia – a cross-

sectional survey. Patient Preference and Adherence, 13, 63–71.

https://doi.org/10.2147/PPA.S176355

AlQarni, K., AlQarni, E. A., Naqvi, A. A., AlShayban, D. M., Ghori, S. A., Haseeb, A., Raafat,

M., & Jamshed, S. (2019). Assessment of Medication Adherence in Saudi Patients With

Type II Diabetes Mellitus in Khobar City, Saudi Arabia. Frontiers in Pharmacology, 10,

1306. https://doi.org/10.3389/fphar.2019.01306

Alshehri, K. A., Altuwaylie, T. M., Alqhtani, A., Albawab, A. A., & Almalki, A. H. (2020). Type

2 Diabetic Patients Adherence Towards Their Medications. Cureus, 12(2), e6932.

https://doi.org/10.7759/cureus.6932

De Villiers, L., & Alhalabi, J. (2015). International Journal of Research in Nursing 2015.

International Journal of Research in Nursing 2015.

Kirkman, M. S., Rowan-Martin, M. T., Levin, R., Fonseca, V. A., Schmittdiel, J. A., Herman, W.

H., & Aubert, R. E. (2015). Determinants of Adherence to Diabetes Medications:

Findings From a Large Pharmacy Claims Database. Diabetes Care, 38(4), 604–609.

https://doi.org/10.2337/dc14-2098

Krass, I., Schieback, P., & Dhippayom, T. (2015). Adherence to diabetes medication: A

systematic review. Diabetic Medicine: A Journal of the British Diabetic Association,

32(6), 725–737. https://doi.org/10.1111/dme.12651

 16

Lamm, K. W., Lamm, A. J., & Edgar, D. (2020). Scale Development and Validation:

Methodology and Recommendations. Journal of International Agricultural and

Extension Education, 27(2), 24–35. https://doi.org/10.4148/2831-5960.1115

Magliano, D. J., Boyko, E. J., & IDF Diabetes Atlas 10th edition scientific committee. (2021).

IDF DIABETES ATLAS (10th ed.). International Diabetes Federation.

http://www.ncbi.nlm.nih.gov/books/NBK581934/

Peh, K. Q. E., Kwan, Y. H., Goh, H., Ramchandani, H., Phang, J. K., Lim, Z. Y., Loh, D. H. F.,

Østbye, T., Blalock, D. V., Yoon, S., Bosworth, H. B., Low, L. L., & Thumboo, J. (2021).

An Adaptable Framework for Factors Contributing to Medication Adherence: Results

from a Systematic Review of 102 Conceptual Frameworks. Journal of General Internal

Medicine, 36(9), 2784–2795. https://doi.org/10.1007/s11606-021-06648-1

Polonsky, W. H., & Henry, R. R. (2016). Poor medication adherence in type 2 diabetes:

Recognizing the scope of the problem and its key contributors. Patient Preference and

Adherence, 10, 1299–1307. https://doi.org/10.2147/PPA.S106821

Wang, X., & Cheng, Z. (2020). Cross-Sectional Studies: Strengths, Weaknesses, and

Recommendations. Chest, 158(1, Supplement), S65–S71.

https://doi.org/10.1016/j.chest.2020.03.012