F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.141632.1 Research Article Articles Measurement of medication adherence among type II diabetes patients attending primary healthcare facilities in Morocco.

[version 1; peer review: 1 approved with reservations]

 Maryem Arraji Conceptualization Data Curation Formal Analysis Funding Acquisition Investigation Methodology Project Administration Resources Software Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-5599-0238 a 1 Nadia Al Wachami Data Curation Methodology 1 Younes Iderdar Resources Software https://orcid.org/0000-0002-8015-4434 1 Chaimaa El Moubchiri Formal Analysis Investigation https://orcid.org/0000-0003-4267-6079 1 Yassmine Mourajid Investigation Methodology 1 Karima Boumendil Project Administration Resources https://orcid.org/0000-0002-8265-4555 1 Fatima Zahra Bouchachi Validation Visualization 1 Morad Guennouni Resources Software Supervision Validation https://orcid.org/0000-0002-3963-1366 1 2 Noureddine El Khoudri Visualization Writing – Original Draft Preparation 1 Mohamed Barkaoui Supervision Validation 3 Chahboune Mohamed Data Curation Formal Analysis Funding Acquisition Methodology Project Administration Validation Visualization 1 Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Sciences and Health Technologies, Settat, 26000, Morocco Chouaîb Doukkali University, Higher School of Education and Training, Science and Technology Team, El Jadida, Morocco Hassan First University of Settat, Institute of Sports Sciences, Settat, 26000, Morocco m.arraji@uhp.ac.ma

No competing interests were disclosed.

 11 10 2023 2023 12 1316 20 9 2023 Copyright: © 2023 Maryem A et al. 2023 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: The aim of this study was to assess medication adherence among Moroccan patients with type 2 diabetes.

Methods: To achieve this objective, a quantitative cross-sectional study was conducted among patients with type 2 diabetes in Morocco. The General Medication Adherence Scale (GMAS) was used to measure medication adherence in this target population. The study received ethical approval from the Moroccan Association for Research and Ethics.

Results: A total of 284 patients were included in the study. Among them, 90.30% of type 2 diabetes patients demonstrated high adherence to their medication treatment, while 5.30% were considered to have moderate adherence and only 4.40% showed partial adherence. However, when the cumulative evaluation of medication adherence towards antidiabetic drugs was conducted, the results confirmed an adherence rate of approximately 95.78%.

Conclusions: The study's findings revealed a high level of medication adherence among type 2 diabetes patients. To sustain these encouraging results, it will be crucial to maintain and value the efforts made by healthcare professionals involved in the care of these patients.

 Medication adherence; type 2 diabetes; oral antidiabetic drugs; Morocco. The author(s) declared that no grants were involved in supporting this work. Introduction

Chronic diseases are physical or even mental conditions that restrict the daily activities of patients, persist for at least a year, and require ongoing medical treatment. 1 , 2 In 2014, in the United States, 60% of people were affected by chronic conditions, including heart diseases, cancer, and diabetes, while 42% were affected by other chronic illnesses. 3 Non-communicable diseases have a significant impact on mortality and result in substantial economic burdens, further increasing healthcare expenditures globally. Statistical data have highlighted that annual healthcare expenditures associated with heart diseases and strokes combined reached 199 billion US dollars, 4 and healthcare expenditures related to diabetes were estimated at 237 billion US dollars in 2018 according to the American Diabetes Association. Global epidemiological statistics indicate a significant increase in the number of individuals with diabetes mellitus (DM), making this chronic condition a leading cause of mortality and morbidity worldwide. 5 Additionally, alongside genetic predispositions, it is crucial to mention the essential role of modifiable factors, such as a sedentary lifestyle and an unhealthy diet, which are fundamental predictors of this chronic disease, the prevalence of which continues to rise. 6 This epidemic has become a major dilemma for global public health services, with 425 million people confirmed to have DM in 2017; this alarming number could reach 693 million by 2045. 7 Indeed, DM stands as the most well-known chronic disorder of the endocrine system. It is noteworthy that improving medication adherence can effectively minimize the economic and health imbalances caused by this DM. For instance, a 10% improvement in treatment adherence among diabetic patients could lead to annual savings of around $450 per affected individual. 8 , 9 Thus, the study of medication adherence is valuable in the effort to mitigate the economic and health burden imposed by this disease. In Morocco, the situation remains alarming, with DM being one of the most common metabolic diseases, recording over 1.4 million cases in 2013, according to the International Diabetes Federation. It should be noted that the number of diagnosed type 2 diabetics each year at primary healthcare institutions. The PHI is 23,761, with 14,479 (66%) in urban areas, compared to 9,282 (34%) in rural areas. Meanwhile, the number of diabetics receiving care within the same facility shows a figure of 1,033,999, with 324,382 (31%) in rural areas and 709,617 (69%) in urban areas, according to statistics from the Moroccan Ministry of Health and Social Protection in 2021. 10 Medication adherence is defined as the extent to which a person's behavior regarding medication intake aligns with the recommendations agreed upon with their healthcare professional. 11 Nevertheless, various studies have noted that non-adherence to medications is a common issue among different patient populations. 12 , 13 In this regard, poor adherence can lead to unfavorable outcomes that could worsen the patient's health, result in additional healthcare costs, and even impact their quality of life. 12 , 14 , 15 Consequently, this constitutes a major public health problem with adverse implications for treatment goals, particularly among patients suffering from chronic diseases. 16 The objective of this study was to assess the level of medication adherence among type 2 diabetic patients who attend primary healthcare institutions in Morocco. To our knowledge, no study has been conducted in this direction so far due to the lack of validated tools specifically designed for the Moroccan context to measure this crucial component. Hence, this recent work is essential as it aims to quantitatively measure adherence using the General Medication Adherence Scale (GMAS), which has been recently translated and validated exclusively for the first time in Morocco. 17 Through this scale, we were able to assess medication adherence within our study population.

 Methods Ethical considerations

The study protocol received approval from RB00012973 Moroccan Association for Research and Ethics IRB #1 [09/REC/22]. Patients were informed about the study and its objectives; they then provided their informed consent to participate via verbal communication. We chose to use verbal consent because we initially identified that a significant portion of our patients were illiterate. In our sample, 78.50% of them cannot read or write. This is why we opted for oral consent from our patients to participate in the study.

 Research design

This cross-sectional study was conducted face-to-face from July 1st to August 1st, 2023, at primary healthcare facilities in Morocco that provide curative and preventive care programs to individuals with chronic diseases. Study participants were adults aged 18 and above, presenting with prediabetes and/or confirmed diabetes, with or without other concurrent conditions, and who had been on antidiabetic treatment for at least one month prior to their inclusion in the study. Patients planning to undergo surgical intervention, pregnant women, and those with acute illnesses requiring urgent medical treatment were excluded from the study. To address issues of reading and comprehension, particularly for illiterate patients, all subjects provided informed consent through verbal communication.

 Participants and recruitment

A total of 284 participants were selected from the registry of the primary healthcare facility.

 Introduction of the General Medication Adherence Scale (GMAS)

In the context of our study aiming to measure medication adherence among patients with type 2 diabetes (T2DM), we employed the General Medication Adherence Scale (GMAS), which was translated and transculturally validated exclusively within the Moroccan context. 17 The scale was originally developed in the Urdu language in December 2017 by Naqvi et al. 18 To translate the instrument from English to Moroccan Arabic, we followed the standard operational procedure of the World Health Organization (WHO). 19 This Moroccan Arabic version of GMAS was translated and validated among Moroccan patients with T2DM, and the results demonstrated that this version met the validity criteria for most of the studied psychometric parameters.

The GMAS is a self-assessment tool consisting of 11 items, with a maximum score of 33. A score ≤ 10 indicates poor medication adherence, a score between 11-16 indicates low adherence, 17-26 indicates partial adherence, 27-29 indicates good adherence, and 30-33 indicates high adherence. This adherence is further subdivided into three constructs:

Patient Behavior-Related Non-Adherence (PBNA): Items 1-5.

Non-Adherence Related to Comorbidities and Medication Burden (ADPB): Items 6-9.

Non-Adherence Related to Costs (CRNA): Items 10-11.

The Cumulative Classification of Overall Medication Adherence (dichotomous) is distributed as follows:

≥ 27 indicates medication adherence.

≤ 26 indicates medication non-adherence.

 Transcultural adaptation and validation of the GMAS tool

Initially, two translators, native speakers of Moroccan Arabic with proficiency in English, performed the translation of the scale. This led to the creation of two versions of the GMAS in Moroccan Arabic at this stage. Both versions were then presented to a panel and examined in terms of conceptual and cultural equivalence. These two versions were harmonized to create a single version in Moroccan Arabic, which was formulated and adopted at this stage. The research team assigned a reviewer proficient in both English and Arabic to develop a back-translation of the measurement instrument. In this way, any discrepancies between the translated and back-translated versions were addressed at this stage. The final version of the GMAS in Moroccan Arabic was tested on 20 subjects. No difficulties were encountered, and the Moroccan Arabic version of the GMAS was deemed satisfactory.

In order to adapt the original English version of the GMAS tool to Moroccan culture, certain terms were added, replaced, or even rearranged. This process helped develop a version understandable for patients with type 2 diabetes, thus overcoming constraints and ambiguities related to intercultural differences.

As for assessing the reliability of the translated GMAS tool, it was tested twice on 20 patients through questionnaires containing the 11 items, administered at a 15-day interval. This time frame was sufficiently long to avoid any influence on the responses provided in the first administration. Reproducibility is considered "good" when the intraclass correlation coefficient (ICC) exceeds 0.4, 20 and internal consistency among different items was estimated using Cronbach's alpha (α) value, which is considered satisfactory for values above 0.7. The response rate to all items was used to evaluate the instrument's acceptability. Thus, the measurement tool was translated and transculturally validated, and it met the majority of psychometric parameters. 17

Data analysis

The collected data were entered and analyzed using the IBM SPSS software, also known as “Statistical Package for Social Sciences,” version 20 (SPSS Inc., Chicago, IL, USA). Demographic data were presented using frequency counts (N) and percentages (%). Statistical tests were chosen based on the data distribution. The Shapiro-Wilk test was used to check data normality. 21 For non-parametric data, the chi-square test (χ 2) and Spearman's correlation (ρ) were used to identify any association between patient characteristics and treatment adherence. Significant associations were indicated by p-values below 0.05 and correlation coefficients within the range of (-1.0 and +1.0).

 Results Sociodemographic data

A total of two hundred eighty-four patients with T2DM participated in the study, with a mean age of 58.24 ± 13.827 years, ranging from 29 to 91 years. Slightly over half of the patients (53.20%) were female, 65.50% were married, and a large majority of participants (78.50%) were illiterate. Most patients were unemployed (91.50%). Almost all patients had medical coverage, primarily provided by the Medical Assistance Program (RAMED), representing 82.81% of all insured individuals ( Table 1).

Sociodemographic information of patients (N=284).
Sociodemographic characteristics N %
Sex
Female 151 53.20
Male 133 46.80
Place of residence
Urban 21 7.40
Rural 263 92.60
Marital status
Single 51 18.00
Married 186 65.50
Widow (er)/Divorced 47 16.50
Level of education
No education 223 78.50
Primary/College/High School 54 19.00
University 7 2.50
Employment status
Unemployed 260 91.50
Retired 12 4.20
Assets 12 4.20
Social security coverage
Insured 256 90.14
Without insurance 28 9.86
Type of health insurance
CNOPS 30 11.71
CNSS 14 5.46
RAMED 212 82.81

CNOPS: National Fund of Social Welfare Organizations; CNSS: National Social Security Fund; RAMED: Medical Assistance Plan.

 Disease and treatment-related characteristics

Approximately 40.50% of participants were on a single antidiabetic medication, with the most common being metformin 1000 mg (37%). Hypertension was the most notable comorbidity (43.70%), followed by dyslipidemia (37.70%). The duration of diabetes diagnosis ranged from 6 to 10 years for 37.70% of subjects; 58.80% reported practicing self-monitoring of their blood glucose, and 58.8% indicated receiving education about their diabetes ( Table 2).

Disease and Treatment-Related Characteristics.
Characteristics related to the disease and treatment N %
Treatment
One OAD 115 40.50
OAD+ Insulin 18 6.30
Two or more OADs 67 23.60
Insulin alone 84 29.60
Name of OAD taken
Glimepiride 2 mg 18 9.00
Gliclazide 60 mg 42 21.00
Metformin 1000 mg 74 37.00
Gliclazide+ Metformin 33 16.50
Glimepiride+ Metformin 33 16.50
Associations pour d’autre maladies
Monotherapy 185 65.10
Dual therapy 88 31.00
Triple therapy and more 11 3.90
Diseases associated with diabetes
AHT 124 43.70
Dyslipidemia 107 37.70
Other pathologies 29 10.20
No associated pathologies 10 3.50
AHT+ Dyslipidemia + Others 14 11.30
Duration of disease
Less than a year 17 6.00
1 to 15 years 226 79.60
21 years and more 18 6.30
Self-monitoring of blood glucose
Yes 167 58.80
No 11 41.20
Information about diabetes
Informed patients 167 58.80
Uninformed patients 117 41.20

AHT: Arterial Hypertension; OAD: Oral Antidiabetic Drugs.

 Medication adherence

Information Patient responses for each item of the GMAS scale ( Table 3) confirmed that almost all patients exhibited high medication adherence (N=257, 90.50%), and none of the patients in our target population had low or poor adherence ( Table 4). The assessment of medication adherence based on different constructs of the scale confirms that 100% of participants had poor adherence in relation to the PBNA construct ( Table 5). The cumulative classification of overall medication adherence shows that 95.78% (N=272) are classified as adherent to medication treatment ( Table 6).

Medication Adherence Information.
GMAS constructs GMAS items/Brief item description Participants’ response (%)
Always Mostly Sometimes Never
PBNA GMAS 1 Difficult to remember taking medications 0. 40 0.40 4.20 95.10
GMAS 2 Forgetfulness in taking medicines due to events, schedules, and travel 0.70 0.40 6.70 92.30
GMAS 3 Discontinuation of medicines when patient feels well 0.40 0.00 5.30 94.40
GMAS 4 Stops medicines when experiences an adverse effect 0.40 0.00 5.30 94.40
GMAS 5 Stops medicines without prior intimation to the doctor 0.40 0.00 5.60 94.00
ADPB GMAS 6 Discontinuation of medication therapy due to medicines for additional disease 0.40 0.00 4.60 95.10
GMAS 7 Hassle to remember medicines due to regime complexity 0.00 0.00 9.20 90.80
GMAS 8 Missing medicines due to disease progression and/or addition of new medicines 0.40 0. 40 8.50 90.80
GMAS 9 Altering medication regimen in any sense 0.00 1.10 6.00 93.00
CRNA GMAS 10 Medicines deemed as unworthy of money spent and discontinued 0.40 1.80 120 85.90
GMAS 11 Difficult to buy costly medicines 1.10 1.40 10.60 87.00

PBNA: Patient behavior related non-adherence; ADPB: Additional disease and pill burden; CRNA: Cost related non-adherence.

 Cumulative Ranking for Overall Medication Adherence (All Categories).
Cumulative grading for overall medication adherence (all categories) N %
High adherence (30-33) 257 90.30
Good adherence (27-29) 15 5.30
Partial adherence (17-26) 12 4.40
Low adherence (11-16) 0 0.00
Poor adherence (0-10) 0 0.00
Caractéristiques de l'observance médicamenteuse selon les différents construits de l'échelle GMAS.
GMAS constructs Levels of adherence
High Good Partial Low Poor
N(%) N(%) N(%) N(%) N(%)
PBNA - - - - 284(100)
ADPB - - 232(81.70) 43(15.10) 9(3.20)
CRNA 232(81.70) 23(8.10) 27(9.50) - 2(0.70)

PBNA: Patient behavior related non-adherence; ADPB: Additional disease and pill burden; CRNA: Cost related non-adherence.

 Cumulative Ranking of Overall Medication Adherence (Dichotomous).
Adherent ≥27 Non-adherent ≤26
N % N %
272 95.78 12 4.22
Discussion

Documenting medication adherence is crucial for evaluating treatment outcomes in the case of chronic conditions, with type 2 diabetes being a prime example. One of the most practical methods to measure medication adherence involves the use of a self-reporting tool. 22 , 23 For this study, we chose the GMAS tool, which we translated and transculturally validated for the first time in Morocco in 2023. 17 Our results demonstrated medication adherence of 95.78%. Among diabetic subjects, 90.30% exhibited high adherence, 5.30% had good adherence, and 4.40% showed partial adherence. Our study aligns with the 2020 study conducted by Naqvi et al for translating the GMAS tool into Arabic in Saudi Arabia, 24 which revealed that the majority of patients had high adherence (42.60%), while 19.10% exhibited good adherence, 32.60% showed partial adherence, 4.30% had low adherence, and a small minority (1.40%) had poor adherence. Similarly, our findings are in harmony with the 2022 study by Allaham et al in the United Arab Emirates, 25 using the same GMAS tool, which also confirmed high adherence of 78.57%. Our results are also consistent with the study conducted by Lasut et al in Riyadh, Saudi Arabia 26 in 2022, using the same measurement scale on elderly individuals. The majority of patients demonstrated high adherence (64.90%), while 21.30% exhibited good adherence, 13.30% showed partial adherence, and a minimal proportion (0.50%) reported low adherence. This alignment is also seen in the Sudanese study by Mahmoud et al in 2021, 27 where 69% showed high adherence, 8.80% had good adherence, 11.40% exhibited partial adherence, and 0.80% had poor adherence. The Vietnamese study by Nguyen et al in 2021, 28 focusing on the translation and transcultural validation of GMAS, concluded that officers had a high adherence rate of 91.70%, while traders had a low adherence rate of 43.80%. Patients with an income between three and five million exhibited a significant cumulative non-adherence rate (≤ 26) of 69.25%. A recent 2023 study in Faisalabad, Pakistan, 29 demonstrated that cognitive-behavioral therapy significantly improved medication adherence in patients with T2DM. For instance, high adherence increased from 7.41% to 37.04%, good adherence increased from 11.12% to 44.45%, partial adherence decreased from 46.15% to 11.12%, and low adherence decreased from 22.23% to 7.41%. Additionally, the study by Sendekie et al in northwest Ethiopia 30 in 2022, using the GMAS tool, found that 76.90% of participants had low adherence. Our results contradict the findings of the study by Naqvi et al in Saudi Arabia 31 in 2019, where GMAS validation in English showed that 17.55% of patients had high adherence, 25.10% had good adherence, 49.70% had partial adherence, 5.80% had low adherence, and 1.80% had poor adherence. For the study by AlQarni et al. in 2019 in Khobar, Saudi Arabia, 32 the data revealed that a little over one-third, 35.80%, of patients were adherent to medication treatment across the three constructs. Among them, half of the patients, 50.90%, exhibited high adherence in the PBNA construct. Furthermore, for the ADPB construct, just under half of the patients, 47.20%, showed high adherence in this regard. Concerning the last CRNA construct, more than half of the subjects, 54.70%, demonstrated high adherence at this level. Although the Vietnamese study conducted by Pham et al. in 2022 33 found that adherence to the PBNA construct was high in 41% of cases, good in 24.40%, partial in 24.60%, low in 7.60%, and poor in 2.40%. For the ADPB construct, adherence to treatment was high in 51.30%, good in 27.20%, partial in 17.50%, low in 2.90%, and even poor in 1.10%. Regarding the last ADPB construct, adherence levels were high in 53.10%, good in 22.50%, partial in 21.60%, low in 1.50%, and even poor in 1.30%.

Strengths and limitations

The present study has some limitations. For instance, the degree of medication adherence was measured through a self-assessment scale completed by patients, which could influence responses and lead to underestimation or overestimation of adherence levels. Despite this limitation, this study is considered the first of its kind to fill the existing gap in the literature concerning factors influencing medication non-adherence in the same target population.

 Conclusions and recommendations

Our study revealed that type 2 diabetic subjects exhibited high medication adherence using the Moroccan GMAS tool (GMAS-M), which has previously demonstrated validity, reliability, and satisfactory psychometric parameters. Its concise and easy-to-understand format allows patients to complete it independently, making it a valuable tool for measuring medication adherence levels among patients with chronic diseases, as well as for identifying potential barriers to adherence. We recommend its use in other chronic diseases.

 Author Contributions

ARRAJI Maryem: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

AL WACHAMI Nadia: Data Curation, Methodology

IDERDAR Younes: Resources, Software

EL MOUBCHIRI Chaimaa: Formal Analysis, Investigation

MOURAJID Yassmine: Investigation, Methodology

BOUMENDIL Karima: Project Administration, Resources

BOUCHACHI Fatima Zahra: Validation, Visualization

GUENNOUNI Morad: Resources, Software, Supervision, Validation

EL KHOUDRI Noureddine: Visualization, Writing – Original Draft Preparation

BARKAOUI Mohamed: Supervision, Validation

CHAHBOUNE Mohamed: Data Curation, Formal Analysis, Funding Acquisition, Methodology, Project Administration, Validation, Visualization

 Data availability Underlying data

Due to the fact that open posting of data on a repository was not included in the study information sheet at the time the survey was done, data access will be granted once users have consented to the data sharing agreement and provided written plans and justification for what is proposed with the data. Data access may be obtained by submitting a request to the authors at Hassan First University of Settat, Higher Institute of Health Sciences, Laboratory of Sciences and Health Technologies, Settat 26000, Morocco.

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Infect Dis. 2022 Jun 13;7(6):101. 35736980 10.3390/tropicalmed7060101 PMC9228239 10.5256/f1000research.155096.r276928 Reviewer response for version 1 Chan Chun Wai 1 Referee https://orcid.org/0000-0002-2217-4955 International Medical University, Sembilan, Malaysia

Competing interests: No competing interests were disclosed.

 29 5 2024 Copyright: © 2024 Chan CW 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

Introduction: Background, rationale and objective of the study were adequately described.

Methods: Cross-sectional design is appropriate for prevalence study. Sample size calculation is missing. GMAS is adequately described. I am confused with the translation and validation part – Did the authors describe the study conducted by Arraji et al or they conducted the translation and validation again themselves? If they described the previous study then can omit most of the information, just describe the relevant statistical results showing the validity of the previous study will do.

Results: The tables describing the frequency of independent and dependant variables were listed, but there is no statistical analysis on the associated factors. Table 5 description isn’t in English.  

Discussions: The authors listed many other studies with the similar results, but did not mention the reasons why the adherence rates were high. Missing the discussion on the associated factors.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Primary care

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.