Topic 2 Assessment
Rosi_226
retrieve2.pdf
R E V I EW
The impact of personal and cultural beliefs on
medication adherence of patients with chronic
illnesses: a systematic review This article was published in the following Dove Press journal:
Patient Preference and Adherence
Wejdan Shahin
Gerard A Kennedy
Ieva Stupans
School of Health & Biomedical Sciences,
RMIT University, Bundoora, Victoria
3083, Australia
Background: Patients’ adherence to therapeutic regimes may be influenced by subjective
beliefs about chronic conditions. One of the challenges for health professionals in enhancing
adherence is taking patients’ understanding into account when giving health advice and/or
providing medical treatment.
Purpose: This review aimed to evaluate the consequent effects of personal and cultural
beliefs on medication adherence, in patients with chronic conditions such as hypertension,
diabetes mellitus, chronic obstructive pulmonary disease and asthma.
Method: A systematic review methodology was used. PubMed, CINAHL, EMBASE and
PsychINFO, databases were searched for relevant articles. The main terms analyzed were illness
perceptions, health beliefs, cultural beliefs, chronic conditions and medication adherence.
Results: From 2,646 articles, 127 were retained for further assessment, and finally 25 met
the inclusion criteria. A cross-sectional questionnaire survey research design was conducted
in all included articles. Of these most (n=22) targeted hypertension or diabetes mellitus.
A number of personal and cultural based factors were identified as being associated with
adherence to medication regimes — 40% of articles (n=10) examined perception of illness,
20% (n=5) health literacy, 16% (n=4) cultural beliefs, 12% (n=3) self-efficacy, 16% (n=4)
spiritual and religious beliefs, as well as 20% (n=5) illness knowledge. Statistically signifi-
cant associations between medication adherence and these personal and cultural factors were
found in 80% (n=20) of the included studies. However, the direction of associations varied
between studies depending on the factor that was examined.
Conclusion: This review has evaluated the impact of personal and cultural factors on
medication adherence and highlighted the gaps in literature regarding adherence. Further
research is required to fully identify the associations between religious beliefs, control beliefs
and illness knowledge and medication adherence.
Keywords: perception of illness, health beliefs, culture, medication adherence, diabetes
mellitus, hypertension, asthma, chronic obstructive pulmonary disease
Introduction Chronic illness is a significant worldwide health problem, with the numbers of
people affected steadily increasing. World Health Organization (WHO) data show
that uncontrolled hypertension rose from 600 million people to nearly one billion
from 1980 to 2008 and in a similar period the number of people with diagnosed
type 2 diabetes mellitus (DMT2) rose from 108 to 422 million. 1,2
The treatment of chronic illnesses commonly includes the long-term use of pharma-
cotherapy. Although medications are effective in addressing chronic illnesses, their full
Correspondence: Wejdan Shahin School of Health & Biomedical Sciences, RMIT University, 289 Mckimmies Road, Bundoora, Victoria 3083, Australia Tel +61 43 496 1996 Email [email protected]
Patient Preference and Adherence Dovepress open access to scientific and medical research
Open Access Full Text Article
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http://doi.org/10.2147/PPA.S212046
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benefits are often not realized due to lack of adherence. Levels
of adequate adherence to diabetes (DMT2) and hypertension
(HTN) treatment regimens vary widely with estimates from
36–93% for DMT2 and 30–70% for HTN.3,4 Up to 50% of
patients who are diagnosed with chronic obstructive pulmonary
disease (COPD) fail to take medications as directed and many
do not use inhalers effectively.5 Similarly, it is estimated that
30–70% of asthma suffers are not adherent to preventative
medications.6 The consequences of non-adherence include;
significant worsening of disease, treatment failure, increased
hospitalizations and increased health care costs.7
Adherence is defined as the process by which patients take
their medication as prescribed8 Patients’ acceptance of medical
advice, including medication use, may be influenced by sub-
jective beliefs about their health condition. Therefore, it is
essential to take beliefs into account when giving health advice
and/or providing medical treatment.3 It has been shown that
medication adherence is multi-faceted. Factors contributing to
medication adherence include illness perceptions, health lit-
eracy, self-efficacy, cognitive abilities such as memory, coping
and problem-solving skills, as well as psychosocial factors such
as personal and cultural beliefs related to medication taking.9
Factors of concern to patients, regarding their illness, may
be conceptualized as patients’ illness perceptions. Leventhal
and his colleagues proposed the common-sensemodel of illness
representation to understand the processes by which people
make sense of illness.10 Illness perceptions are personal beliefs
and expectations about an illness or somatic symptoms. The
basic assumption underlying this model is that illness percep-
tions, along with “common sense,” are used in interpreting the
meaning of illness or somatic symptoms, deciding on
a response, and evaluating the effectiveness of the response.11
Personal beliefs about illness include both cognitive
and emotional representations. Cognitive beliefs include
five core domains: (1) “identity” describes peoples’ beliefs
about the label of illness and symptoms, and sets out the
targets for change (such as to eliminate symptoms); (2)
“timeline” refers to people’s perception of the duration of
illness, including symptoms and recovery; (3) “conse-
quences” refers to beliefs about the seriousness of the
disease and the impacts on daily life; (4) “control” refers
to perceptions about the amenability of the illness to being
cured, prevented or treated; and (5) “causes” refers to
people’s perceptions of the possible causes of their condi-
tion. Emotional representations are the feelings that arise
as a result of illness, such as anxiety and/or depression.12
In explaining health behaviors, social determinants
such as spirituality and religiosity have been increasingly
identified as impacting health and treatment.7 Though
often used interchangeably, spirituality and religiosity are
separate, but related, concepts. While spirituality denotes
an inner freedom to engage in faith and a relationship with
a Supreme Being, such as God, religion refers to the out-
ward adherence to highly prescribed beliefs, practices and
rituals related to the Supreme Being, such as church atten-
dance and associated activities.13 Cultural beliefs, defined
as “a set of behavioral patterns related to thoughts, man-
ners and actions, which members of society have shared
and passed on to succeeding generations”14 may also
influence the decision making of patients with chronic
disease to take medication.14 Acculturation has been
defined as culture change that results from continuous
contact between two distinct cultural groups; it also refers
to changes in an individual whose cultural group is collec-
tively experiencing acculturation.15
Health behaviors in the self-management of chronic
diseases can also be affected by both health literacy and
self-efficacy.16 High health literacy, ie, “the cognitive and
social skills which determine the motivation and ability of
individuals to gain access to, understand and use informa-
tion in ways which promote and maintain good health”17
and high self-efficacy, ie, “the belief in one’s capacity to
organize and execute the courses of action required to
manage a prospective situation“17 are more likely to have
better adherence to self-care tasks and medication
adherence.18
In this review, we update and expand an earlier review9
to take into account findings from recent literature. Since
2006, a number of studies have been published which have
examined illness perceptions conceptualized by the com-
mon sense model. Secondly, studies examining the impact
of acculturation and religious beliefs on medication adher-
ence have now also been published.
Although a number of systematic reviews on medication
adherence have been conducted,12,19–21 none of these has
explored the relationship between medication adherence and
personal and cultural beliefs of patients with chronic diseases
such as HTN, COPD, asthma and DMT2. These chronic dis-
eases are currently the most significant in terms of population
health in first-world countries.
Methods Search strategy The Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) guidelines22 were followed. The
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electronic databases (CINHAL, EMBASE, PsychINFO and
PubMed) were systematically and extensively searched to
identify the articles related to the effect of personal and
cultural beliefs on medication adherence in chronically ill
patients with HTN, DMT2, COPD and asthma. Outlined in
Table 1 is the combination of search terms that were used to
source the relevant literature. The search was conducted in
August 2018, and rechecked in May 2019. This review is an
update of a previously published systematic review;9 there-
fore, limitations were placed around the search strategy,
March 2006–December 2018.
Study selection Studies that met the inclusion criteria were selected initially,
based on screening the titles and abstracts by one researcher
(W.S.). Copies of the full-text papers deemed potentially
relevant by the first screening were subsequently, indepen-
dently fully analyzed by two researchers (W.S. and I.S.); in
cases of disagreement about inclusion, the third author
(G.K.) was consulted and consensus was reached.
Inclusion criteria Articles were included if: (1) they pertained to one of the four
main chronic illnesses: DMT2, HTN, COPD or asthma; (2)
included a clear method of how medication adherence and
beliefs were measured; and (3) addressed the association of
beliefs and medication adherence.
Exclusion criteria Articles were excluded if: (1) not peer-reviewed articles;
(2) written in a language other than English; (3) focused
on illnesses other than HTN, DMT2, COPD or asthma; (4)
mentioned self-management behaviors, but not medication
adherence; and (5) assessed the effect of medication
beliefs on medication adherence.
Data extraction process The data extracted from each eligible paper were synthe-
sized and are presented in Tables 2–5. Table 2 shows
a summary of major findings of the studies which exam-
ined the association of illness beliefs with medication
adherence, Table 3 shows a summary of religious, cul-
tural and personal and illness knowledge effects on med-
ication adherence and Table 4 shows a summary of the
impact of health literacy and self-efficacy on medication
adherence.
Demographic characteristics and the tools used to measure
beliefs and medication adherence are presented in Table 5.
Table 1 Review search terms and databases reviewed
Database Search terms
PubMed (Medication compliance OR medication taking behaviour OR medication adherence) AND (health beliefs OR religious beliefs
OR common sense model OR self-efficacy OR illness perception OR health literacy OR (“Health Knowledge, Attitudes,
Practice”[Mesh]) OR (“Culture”[Mesh])) AND (asthma OR diabetes mellitus OR chronic obstructive pulmonary disease OR
hypertension)
Limiters – published date: 01/03/2006–01/01/2019; journal articles
CINAHL with full
text
Chronic obstructive pulmonary disease OR diabetes mellitus OR asthma OR hypertension AND medication adherence OR
medication compliance OR medication persistence OR drug adherence OR drug compliance AND health beliefs OR illness
perception OR patient beliefs OR cultural beliefs OR common sense model OR acculturation OR health knowledge OR
health literacy OR self-efficacy OR religious beliefs
Limiters – published date: 01/03/2006–01/01/2019
Embase (“chronic obstructive pulmonary disease” OR “diabetes mellitus” OR asthma OR hypertension) AND (“medication adher-
ence” OR “medication compliance” OR “medication persistence” OR “drug adherence” OR “drug compliance”) AND
(“health beliefs” OR “illness perception” OR “patient beliefs” OR “cultural beliefs” OR “common sense model” OR
acculturation OR “health knowledge” OR “health literacy” OR “self-efficacy” OR “religious beliefs”)
Limiters – published date: 2006–2019
PsychINFO Chronic obstructive pulmonary disease OR diabetes mellitus OR asthma OR hypertension AND medication adherence OR
medication compliance OR medication persistence OR drug adherence OR drug compliance AND health beliefs OR illness
perception OR patient beliefs OR cultural beliefs OR common sense model OR acculturation OR health knowledge OR
health literacy OR self-efficacy OR religious beliefs
Limiters – Peer reviewed; published date: 01/03/2006–01/01/2019
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Risk of bias in individual studies To ascertain the validity of eligible cross-sectional studies,
each study was assessed for the following eight compo-
nents based on the checklist for quasi-experimental studies
(non-randomized experimental studies):23 (1) clearly
defining the criteria for inclusion in the sample; (2)
detailed description of the study subjects and the setting;
(3) validity and reliability of ways measuring the expo-
sure; (4) criteria used for measurement of the condition;
(5) identifying confounding factors; (6) strategies to deal
with confounding factors; (7) validity and reliability of the
outcomes measures and (8) appropriate statistical analyses
used.
Results Article selection The literature search located 2,642 articles; hand searching
retrieved four additional references. Subsequently, 937 dupli-
cateswere removed, and the titles and abstracts of the remain-
ing 1,673 articles were reviewed. 127 articles were directly
related to the aims of this review. A further detailed review of
the full-text articles resulted in elimination of additional 102
Table 2 Summary of associations between illness perceptions and medication adherence
Study Association between illness perceptions and medication adherence
Chen et al, 201130 Significant association between illness perceptions variables and medication adherence:
Medication adherence associated positively with treatment control and personal control (β=0.41, p<0.05).
Medication adherence associated negatively with illness identity (β=0.23, p<0.05), and cause of illness (β= −0.25,
p<0.05).
Ashur et al, 201531 Significant association between Illness perceptions variables and medication adherence:
Medication adherence associated positively with treatment control (p=0.04, OR=0.95, 95% CI=0.91–0.99).
Medication adherence associated negatively with illness identity (p=0.008, OR=1.08, 95% CI=1.02–1.14).
Chen et al, 200929 Significant associations between illness perceptions variables and medication adherence:
Medication adherence associated positively with personal control (β=0.14, p<0.05) and treatment control (β=0.20,
p<0.001).
No significant association between illness identity and medication adherence (β= −0.09, p>0.05).
No significant association between emotional representation of illness and medication adherence (β= −0.09, p>0.05).
Medication adherence associated negatively with psychological cause of illness (β= −0.23, p<0.001) and illness con-
sequences (β= −0.12, p<0.05).
Mann et al, 20094 Significant associations were found between illness perceptions variables and medication adherence:
Medication adherence associated positively with personal control (p=0.003).
Medication adherence associated negatively with beliefs about illness consequences (p=0.03) and identity (p=0.002).
Jacobs et al, 201411 Significant moderate associations were found between illness perceptions variables and medication adherence:
Medication adherence associated negatively with beliefs about illness consequences (r=0.383, p<0.05).
Medication adherence associated negatively with illness emotional representation (r=0.528, p<0.001).
Hsiao et al, 20123 Significant associations between illness perceptions variables and the adherence:
Medication adherence associated positively with positive beliefs with regard to timeline, consequences and emotional
responses (p<0.05)
Medication adherence associated negatively with personal control (p<0.05).
Saarti et al, 201632 No significant association between illness perceptions and medication adherence (p=0.52, OR=1.0, CI=0.9–1.0).
Krauskopf et al, 20155 No significant association between illness identity (p=0.46), consequences (p=0.15), personal control (p=0.76), timeline
of illness (p=0.79) with medication adherence.
Negative association between emotional representation of illness and medication adherence (p=0.001)
Rajpura & Nayak, 201425 Positive association between threatening perceived illness burden and medication adherence (r=0.332, p<0.001).
Aflakseir, 201234 Significant association between illness perceptions variables and the adherence:
Medication adherence associated positively with illness timeline (p<0.05).
Medication adherence associated negatively with illness consequences (p<0.05).
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T ab
le 3 A ss o ci at io n o f o th e r fa ct o rs
an d b e lie fs o n m e d ic at io n ad h e re n ce
S tu d y
R el ig io u s b el ie fs
C u lt u ra l b el ie fs
Il ln es s kn
ow le d ge
/p er so
n al
p er ce
p ti o n s
E h e t al , 2 0 1 6 4 0
N e ga ti ve
as so ci at io n b e tw
e e n st ro n g b e lie fs in
th e su p e ri o ri ty
o f tr ad it io n al
C h in e se
m e d ic in e s an d m e d ic at io n ad h e re n ce
(β = − 0 .1 9 , p=
0 .0 2 ). P o si ti ve
co r-
re la ti o n b e tw
e e n ac cu lt u ra ti o n an d m e d ic at io n ad h e re n ce
β= 0 .2 5 , p=
0 .0 0 4 )
L i e t al , 2 0 0 6 2 7
N e ga ti ve
as so ci at io n b e tw
e e n su sc e p ti b ili ty
an d m e d ic at io n ad h e re n ce
(O R = 3 .7 7 , 9 5 %
C I 1 .1 9 – 1 2 .0 1 ).
N e ga ti ve
as so ci at io n b e tw
e e n st ro n g b e lie fs in
th e su p e ri o ri ty
o f C h in e se
h e rb s
an d m e d ic at io n ad h e re n ce
(O R = 2 .2 , 9 5 %
C I= 1 .0 2 – 4 .8 1 ).
N e ga ti ve
as so ci at io n b e tw
e e n lo w e r p e rc e iv e d b e n e fi t o f W e st e rn
m e d ic at io n s
fo r h yp e rt e n si o n an d m e d ic at io n ad h e re n ce
(O R = 2 .7 8 , 9 5 %
C I= 1 .1 3 – 6 .8 4 ).
N e ga ti ve
as so ci at io n b e tw
e e n lo n ge r le n gt h o f st ay
in th e U n it e d S ta te s an d
m e d ic at io n ad h e re n ce
(O R = 2 .4 8 , 9 5 %
C I= 1 .1 2 – 5 .5 0 )
C h iu
e t al ,
2 0 1 4 3 7
N e ga ti ve
as so ci at io n b e tw
e e n u si n g tr ad it io n al h e rb al m e d ic in e s an d m e d ic at io n
ad h e re n ce
S ig n ifi ca n t p o si ti ve
as so ci at io n b e tw
e e n
p at ie n ts ’ u n d e rs ta n d in g o f th e d is e as e an d
m e d ic at io n ad h e re n ce
(p < 0 .0 1 )
A lb ar ga w i e t al ,
2 0 1 7 3 3
S ig n ifi ca n t p o si ti ve
as so ci at io n b e tw
e e n re lig io u s
b e lie fs an d m e d ic at io n ad h e re n ce
(p = 0 .0 4 )
K re tc h y e t al ,
2 0 1 3 7
S p ir it u al b e lie fs n e ga ti ve ly as so ci at e d w it h m e d ic a-
ti o n ad h e re n ce
(p = 0 .0 2 ), w h e re as
n o as so ci at io n
w it h re lig io u s b e lie fs (p = 0 .4 7 )
N az ir e t al ,
2 0 1 6 3 6
P o si ti ve
as so ci at io n b e tw
e e n p at ie n ts ’ k n o w l-
e d ge
ab o u t D M T 2 an d m e d ic at io n ad h e re n ce
(r = 0 .0 4 , p<
0 .0 5 )
K u & K e ge ls ,
2 0 1 5 3 5
P o si ti ve
as so ci at io n b e tw
e e n ill n e ss
k n o w l-
e d ge
an d se lf -m
an ag e m e n t p ra ct ic e s, an d
m e d ic at io n ad h e re n ce
(p = 0 .0 0 7 )
S m al l e t al ,
2 0 1 2 2 4
N o as so ci at io n b e tw
e e n d ia b e ti c k n o w le d ge
an d m e d ic at io n ad h e re n ce
(C on tin ue d)
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articles. We selected a final set of 25 articles that met the
inclusion criteria. For article screening and the exclusion
process, please see the PRISMA Flow Chart (Figure 1).
Characteristics of selected studies All studies selected were cross-sectional and included
surveys. Most of the studies were focused on patients
diagnosed with DMT2 (44%, 11/25) or HTN (44%, 11/
25). An additional two studies were conducted in patients
with asthma, and only one study focused on COPD. Illness
perception was the most frequently investigated belief
reported in 42% (8/19) of the studies.
Eleven of the studies were conducted in the United
States of America,4,5,11,13,16,18,24–28 three in Taiwan,3,29,30
four in Middle-Eastern countries (Lebanon, Libya, Saudi
Arabia and Iran),31–34 one in the Philippines,35 one in
Pakistan,36 one in Ghana,7 one in unspecified Asian
countries,37 one in Poland,38 one in Thailand39 and one
in Australia.40 A number of personal- and cultural-based
factors were identified as being associated with adherence
to medication regimes. These included; perception of ill-
ness, health beliefs and literacy, cultural beliefs, spiritual
and religious beliefs, as well as illness knowledge.
Risk of bias across studies All the studies provided clear, detailed and specific inclusion
criteria to recruit study participants and provided a specific
diagnosis for the participants. Both the exposure and the
outcome were measured in valid and reliable ways; reliable
and valid questionnaires (Cronbach’s alpha =0.6–0.79) have
been used in all the included studies. Confounding factors
were identified and addressed in 24 studies. Although con-
venience samples were used in all the studies, representa-
tiveness of the sample was described as one of the
limitations in most of the included articles, and most also
reported that generalization of results might be limited.
Findings of individual studies Perception of illness
Nine studies investigated the role of beliefs related to
emotional and cognitive domains of chronic illnesses on
medication adherence.3–5,11,29–32,34 These beliefs were
found to be associated with medication adherence in
seven studies.3–5,11,29–31 One study reported that medica-
tion adherence was affected only by the patients’ evalua-
tion of the process of taking medication, its short-termT ab
le 3 (C
o n ti n u e d ).
S tu d y
R el ig io u s b el ie fs
C u lt u ra l b el ie fs
Il ln es s kn
ow le d ge
/p er so
n al
p er ce
p ti o n s
A b e l e t al ,
2 0 1 7 1 3
T h e re
w as
a n o n -s ig n ifi ca n t co rr e la ti o n b e tw
e e n
m e d ic at io n ad h e re n ce
an d th e fo u r sp ir it u al /r e li-
gi o u s va ri ab le s:
A tt e n d in g ch u rc h /r e lig io u s se rv ic e s (p = 0 .0 8 )
P ra yi n g (p = 0 .4 3 )
R e ad in g B ib le /r e lig io u s m at e ri al (p = 0 .1 9 )
S tr e n gt h o f sp ir it u al b e lie fs (p = 0 .5 4 )
Ja n k o w sk a
e t al , 2 0 1 6 3 8
P o si ti ve
si gn ifi ca n t as so ci at io n b e tw
e e n m e d i-
ca ti o n ad h e re n ce
an d h ig h le ve l o f ill n e ss
k n o w le d ge
(β = 0 .2 0 8 ; p=
0 .0 0 1 ).
T ai la k h e t al ,
2 0 1 6 2 8
A cc u lt u ra te d p ar ti ci p an ts
w e re
m o re
ad h e re n t to
m e d ic at io n s an d p h ys ic al
ac ti vi ty
an d h ad
b e tt e r b lo o d p re ss u re
co n tr o l.
A b b re vi at io n : D M T 2 , ty p e 2 d ia b e te s m e lli tu s.
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effects and the longer term outcomes associated with tak-
ing it (Table 2).32
Five studies described beliefs that related medication
adherence to control beliefs (personal and/or treatment
control).3,4,29–31 These beliefs were significantly and posi-
tively associated with medication adherence in four
studies,4,29–31 and negatively associated in only one
study, which found that patients who felt unable to control
their blood pressure were more adherent to medications
(Table 2).3
Five studies explored beliefs about illness identity.4,5,29–31
A negative association with medication adherence was found
in three studies, which suggested that patients who experience
more symptoms may perceive less ability to control their
illness (Table 2).4,30,31 Two studies found no significant asso-
ciation between illness identity and medication adherence
(Table 2).5,29
Five studies examined the association of beliefs related
to illness consequences with medication adherence.3,4,11,29,34
A negative association was found in four studies4,11,29,34
whereas one study found a positive correlation.3 Three stu-
dies mentioned beliefs about the timeline of illness.3,29,34
Two studies demonstrated negative association with medica-
tion adherence,3,29 whereas one study found that patients
who believe that diabetes is a chronic illness have higher
level of adherence34 (Table 2).
Two studies found an association of perceived causes
of illnesses and adherence.29,30 More casual attributions to
psychological factors and less attribution to causality of
risk factors were negatively associated with medication
adherence (Table 2).29,30 Cause was associated positively
with illness identity; individuals who reported more symp-
toms tend to seek more causal attributions, perceived the
illness to be more negative and less controllable, and
therefore were less likely to adhere to medication.30
Four studies explored the effect of emotional represen-
tations of illness on medication adherence,3,5,11,29 and three
of them found that negative emotional representations cor-
related negatively with medication adherence3,5,11 (Table 2),
whereas no significant association was found in the fourth
study (Table 2).29
One study provided insights into how illness percep-
tions and burden relate to medication adherence. Findings
suggested positive significant association between medica-
tion adherence and the threatening view of illness, whereas
there was a negative association with a greater perceived
burden of illness (Table 2).25
Cultural beliefs
Four studies investigated the influence of cultural beliefs
on adherence and self-management (Table 3).27,28,37,40
Participants in one study who had stronger beliefs in the
effectiveness of Traditional Chinese Medication and tradi-
tional Chinese health beliefs were found to be less likely to
be acculturated and less adherence to self-management and
medication.40 Another study focusing on Arab Americans
Table 4 Association of health literacy and self-efficacy on medication adherence
Study Health literacy Self-efficacy
Ku & Kegels, 201535 Positive association identified between perceived self-
efficacy and all four self-management practices (diet
p<0.001, medication adherence p=0.004, health care
provider consultation p<0.001 and exercise p<0.001)
Shiyanbola et al, 201726 No direct relationship with medication adherence; how-
ever, mediated other factors related to medication
adherence, such as illness perception (β=0.20, p=0.002)
and medication beliefs (β= −0.156, p=0.014)
Significant positive association between self-efficacy and
adherence (β=0.486, p<0.001)
Soones et al, 201718 Directly associated positively with medication adherence
(β=0.089, p<0.001) and indirectly mediated by medica-
tion concerns (β=0.03, p=0.002).
Huang et al, 201816 No significant association with diabetes medication
adherence (β = −0.04, p=0.59).
Significant positive association between self-efficacy and
adherence (β =0.53, p<0.001)
Wannasirikul et al, 201639 Directly associated positively with medication adherence
(β=0.08, p<0.05), and indirectly mediated by literacy (β
=0.17, p<0.05) and cognitive ability (β=0.02, p<0.05)
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T ab
le 5 M e as u re m e n t to o ls u se d fo r b e lie fs an d m e d ic at io n ad h e re n ce
B ib lio
gr ap
hy C h ro
n ic
co n d it io n
D em
o gr ap
h ic s ch
ar ac
te ri st ic s
M ea
su re m en
t o f b el ie fs
M ea
su re m en
t o f m ed
ic at io n
ad h er en
ce A ge
(M ea
n )
G en
d er
P ar ti ci p an
ts o ri gi n /
cu lt u ra l gr o u p s
Il ln es s
d u ra ti o n
(m ea
n )
M al e
N (%
)
F em
al e
N (%
)
K ra u sk o p f e t al ., 2 0 1 5 ,5
U S A
C O P D
6 2 – 7 4
6 2 (3 3 )
1 2 6 (6 7 )
E n gl is h - & S p an is h -
sp e ak in g p at ie n ts
in
N e w
Y o rk
N /A
B ri e f Il ln e ss
P e rc e p ti o n s Q u e st io n n ai re
4 6 an d B e lie fs
ab o u t M e d ic at io n s Q u e st io n n ai re
4 7
M e d ic at io n A d h e re n ce
R at in g
S ca le
(M A R S )4 8
H si ao
e t al ,
2 0 1 2 ,3 T ai w an
H T N
5 3 .8
7 8 (6 6 .7 )
3 9 (3 3 .3 )
T ai w an e se
in T ai w an
N /A
Il ln e ss
P e rc e p ti o n Q u e st io n n ai re
– re vi se d 2 9
H yp e rt e n si ve
P at ie n t’s
D ru g
A d h e re n ce
Q u e st io n n ai re
4 9
S aa rt i e t al ,2 0 1 6 ,3 2
L e b an o n
H T N
> 1 8
5 9 (5 0 .4 )
5 8 (4 9 .6 )
L e b an e se
p at ie n ts
in
L e b an o n
7 .8
B ri e f Il ln e ss
P e rc e p ti o n Q u e st io n n ai re
4 6 an d
T re at m e n t S at is fa ct io n Q u e st io n n ai re
fo r
m e d ic at io n 5 0
8 -i te m
M o ri sk y M e d ic at io n
A d h e re n ce
S ca le 5 1
C h e n e t al , 2 0 1 1 ,3 0
T ai w an
H T N
6 5 .2
2 1 4 (6 0 .3 )
1 4 1 (3 9 .7 )
T ai w an e se
p at ie n ts
in
T ai w an
(e th n ic C h in e se )
1 0 .4 5
Il ln e ss
P e rc e p ti o n Q u e st io n n ai re
– R e vi se d 2 9
M e d ic at io n A d h e re n ce
In ve n to ry
an d th e In ve n to ry
o f A d h e re n ce
to
S e lf -M
an ag e m e n t2 1
A sh u r e t al , 2 0 1 5 ,3 1
T ri p o li
D M T 2
5 4 .4
2 1 5 (4 1 .1 )
3 1 8 (5 8 .9 )
L ib ya n p at ie n ts
in T ri p o li
9 .4
Il ln e ss
P e rc e p ti o n Q u e st io n n ai re
– R e vi se d 2 9
8 - It e m s M o ri sk y M e d ic at io n
A d h e re n ce
S ca le 5 1
S o o n e s e t al ., 2 0 1 7 ,1 8
U S A
A st h m a
6 7
7 0 (1 6 .2 )
3 6 3 (8 3 .3 )
E ld e rl y p at ie n ts
fr o m
N e w
Y o rk
in U S A
3 1 .4
B ri e f Il ln e ss
P e rc e p ti o n s Q u e st io n n ai re ,4 6 B e lie fs
ab o u t M e d ic at io n s Q u e st io n n ai re
4 an d S h o rt
Te st o f
F u n ct io n al H e al th
L it e ra cy
in A d u lt s5
2
M e d ic at io n A d h e re n ce
R at in g
S ca le
(M A R S )4 8
C h e n e t al , 2 0 0 9 ,2 9
T ai w an
H T N
> 1 8
1 6 6 (5 9 .9 )
1 1 1 (4 0 .1 % )
T ai w an e se
p at ie n ts
in
T ai w an
1 0 .4 6
Il ln e ss
p e rc e p ti o n q u e st io n n ai re
– R e vi se d 2 9
M e d ic at io n A d h e re n ce
In ve n to ry
an d th e In ve n to ry
o f A d h e re n ce
to
S e lf -M
an ag e m e n t2 1
Ja co b s e t al , 2 0 1 4 ,1 1
U S A
D M T 2
5 4 .6
2 0 (5 0 )
2 0 (5 0 )
L u m b i In d ia n tr ib e in
U S A
9 .9
Il ln e ss
P e rc e p ti o n s Q u e st io n n ai re
– R e vi se d 2 9
M o ri sk y M e d ic at io n A d h e re n ce
S ca le
(o ld
ve rs io n )5 1
R aj p u ra
& N ay ak ,
2 0 1 4 ,2 5 U S A
H T N
> 5 5
7 5 (6 4 .1 )
4 2 (3 5 .9 )
A m e ri ca n e ld e rl y
> 7 ye ar s
B ri e f Il ln e ss
P e rc e p ti o n Q u e st io n n ai re
4 6
B e lie fs o f M e d ic at io n Q u e st io n n ai re
4 7
M o ri sk y M e d ic at io n A d h e re n ce
S ca le
(o ld
ve rs io n )5 1
M an n e t al , 2 0 0 9 ,4 U S A
D M T 2
5 7
4 9 (3 2 )
1 0 2 (6 8 )
E n gl is h - an d S p an is h -
sp e ak in g p at ie n ts
in
N e w
Y o rk /U S A
1 3 .0
B ri e f- Il ln e ss
P e rc e p ti o n Q u e st io n n ai re
4 6
B e lie fs ab o u t M e d ic in e s Q u e st io n n ai re
4 7
M o ri sk y M e d ic at io n A d h e re n ce
S ca le
(o ld
ve rs io n )5 1
(C on tin ue d)
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T ab
le 5 (C
o n ti n u e d ).
B ib lio
gr ap
hy C h ro
n ic
co n d it io n
D em
o gr ap
h ic s ch
ar ac
te ri st ic s
M ea
su re m en
t o f b el ie fs
M ea
su re m en
t o f m ed
ic at io n
ad h er en
ce A ge
(M ea
n )
G en
d er
P ar ti ci p an
ts o ri gi n /
cu lt u ra l gr o u p s
Il ln es s
d u ra ti o n
(m ea
n )
M al e
N (%
)
F em
al e
N (%
)
S h iy an b o la e t al , 2 0 1 7 ,2 6
U S A
D M T 2
5 8 .7
7 4 (4 2 .5 )
1 0 0 (5 7 .5 )
A m e ri ca n p at ie n ts
in
U S A
9 .6
B e lie fs in
M e d ic in e s Q u e st io n n ai re ,4 7 B ri e f- Il ln e ss
P e rc e p ti o n s Q u e st io n n ai re
4 6 an d N e w e st
V it al
S ig n 5 3
8 - It e m s M o ri sk y M e d ic at io n
A d h e re n ce
S ca le 5 1
K u & K e ge ls , 2 0 1 5 ,3 5
P h ili p p in e s
D M T 2
6 2 .8
2 2 7 (4 1 .3 )
3 2 2 (5 8 .7 )
F ili p in o p at ie n t in
P h ili p p in e s
7 .0
B ri e f D ia b e te s K n o w le d ge
T e st , th e D ia b e te s
K n o w le d ge
Q u e st io n n ai re , an d D ia b e te s C ar e
P ro fi le
su rv e y q u e st io n n ai re
5 4 – 5 6
M e d ic al re co rd s re vi e w
N az ir e t al , 2 0 1 6 ,3 6
P ak is ta n
D M T 2
5 0 .8
2 2 2 (5 6 .6 )
1 7 0 (4 3 .4 )
P ak is ta n i p at ie n ts
in
P ak is ta n
5 .5 8
M ic h ig an
D ia b e te s K n o w le d ge
T e st 5 7
U rd u ve rs io n o f M o ri sk y
M e d ic at io n A d h e re n ce
S ca le 5 8
C h iu
e t al , 2 0 1 4 ,3 7 A si a
A st h m a
5 3 .0
4 0 2 (3 8 .2 )
6 5 1 (6 1 .8 )
A si an
p at ie n ts
in C h in a,
K o re a, M al ay si a, T ai w an ,
T h ai la n d an d V ie tn am
1 1 .4
A st h m a C o n tr o l T e st , an d th e S ta n d ar d iz e d A st h m a
(A Q L Q -S )5 9
Q u al it y o f L if e Q u e st io n n ai re
6 0
8 -I te m s M o ri sk y M e d ic at io n
A d h e re n ce
S ca le 5 1
S m al l e t al , 2 0 1 2 ,2 4 U S A
D M T 2
> 1 8
2 6 1 (6 9 .1 )
1 1 6 (3 0 .9 )
E n gl is h -s p e ak in g p at ie n ts
in so u th e as te rn
U n it e d
S ta te
N /A
D ia b e te s K n o w le d ge
Q u e st io n n ai re
5 5
M o ri sk y A d h e re n ce
S ca le
(o ld
ve rs io n )6 1
A lb ar ga w i e t al , 2 0 1 7 ,3 3
K in gd o m
o f S au d i
A ra b ia
D M T 2
4 9
1 8 (6 0 )
1 2 (4 0 )
S au d i p at ie n ts
in K S A
N /A
A ra b ic ve rs io n o f fo rm
C o f th e m u lt id im e n si o n al
h e al th
lo cu s o f co n tr o l sc al e 6 2
T h e A ra b ic ve rs io n o f th e re vi se d
an d e x p an d e d su m m ar y o f d ia -
b e te s se lf -c ar e ac ti vi ti e s sc al e 6 2
E h e t al , 2 0 1 6 ,4 0
A u st ra lia
D M T 2
6 2 .9
6 2 (4 4 .6 )
7 7 (5 5 .4 )
C h in e se
in A u st ra lia
1 2 .5
L e ve l o f ac cu lt u ra ti o n .6 3 B e lie fs in
T C M
an d
W e st e rn
m e d ic in e ; C h in e se
h e al th
b e lie fs 6 4
C h in e se
ve rs io n o f M o ri sk y
M e d ic at io n A d h e re n ce
S ca le 6 5
K re tc h y e t al , 2 0 1 3 ,7
G h an a
H T N
5 7 .1 0
7 4 (3 7 .2 5 )
1 2 5 (6 2 .7 5 )
G h an ai an
p at ie n ts
in
G h an a
≤ 1 0
S p ir it u al P e rs p e ct iv e S ca le 6 6 an d D u k e R e lig io n
In d e x 6 7
8 -I te m s M o ri sk y M e d ic at io n
A d h e re n ce
S ca le 5 1
L i e t al , 2 0 0 6 ,4 3 U S A
H T N
7 0 .6
1 0 0 (5 0 )
1 0 0 (5 0 )
W h it e A m e ri ca n V S
A fr ic an
A m e ri ca n in
U S A
N /A
F o u r- it e m
in st ru m e n t th at
as se ss e d e ac h d im e n si o n
o f H al l’s
fr am
e w o rk
o f p at ie n t tr u st
in th e
p h ys ic ia n 6 8
S e lf -r e p o rt e d (P at ie n ts
w e re
as k e d
to re sp o n d to
a si n gl e q u e st io n )
(C on tin ue d)
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T ab
le 5 (C
o n ti n u e d ).
B ib lio
gr ap
hy C h ro
n ic
co n d it io n
D em
o gr ap
h ic s ch
ar ac
te ri st ic s
M ea
su re m en
t o f b el ie fs
M ea
su re m en
t o f m ed
ic at io n
ad h er en
ce A ge
(M ea
n )
G en
d er
P ar ti ci p an
ts o ri gi n /
cu lt u ra l gr o u p s
Il ln es s
d u ra ti o n
(m ea
n )
M al e
N (%
)
F em
al e
N (%
)
A b e l e t al ,0 .2 0 1 7 ,1 3
U S A
H T N
1 9 – 6 0
– 8 0 (1 0 0 )
B la ck
w o m e n in
U S A
N /A
N in e sp ir it u al /r e lig io u s q u e st io n s d e ve lo p e d b y th e
in ve st ig at o r6
9
1 4 -i te m
H ill -B o n e C o m p lia n ce
to
H ig h B lo o d P re ss u re
T h e ra p y
sc al e 7 0
A fl ak se ir , 2 0 1 2 ,3 4 Ir an
D M T 2
4 0 .7
2 2 (2 2 )
7 8 (7 8 )
Ir an ia n p at ie n ts
in Ir an
9 .5
Il ln e ss
p e rc e p ti o n q u e st io n n ai re
– R e vi se d 2 9
M e d ic at io n A d h e re n ce
R at in g
S ca le 4 8
H u an g e t al , 2 0 1 8 ,1 6
U S A
D M T 2
5 8 .7
7 4 (4 2 .5 )
1 0 0 (5 7 .5 )
E n gl is h -s p e ak in g p at ie n ts
in a M id w e st e rn
st at e in
U S A
9 .6
N e w e st
V it al S ig n 5 3 an d S e lf -E ffi ca cy
fo r
A p p ro p ri at e M e d ic at io n U se
S ca le 7 1
8 -I te m s M o ri sk y M e d ic at io n
A d h e re n ce
S ca le 5 1
Ja n k o w sk a e t al , 2 0 1 6 ,3 8
P o la n d
H T N
3 2 – 9 0
1 0 9 (4 6 .8 )
1 2 4 (5 3 .2 )
P o la n d p at ie n ts
in P o la n d
1 1 .7 5
H yp e rt e n si o n K n o w le d ge
L e ve l S ca le 7 2
8 -I te m s M o ri sk y M e d ic at io n
A d h e re n ce
S ca le 5 1
T ai la k h e t al , 2 0 1 6 ,2 8
U S A
H T N
2 9 – 7 4
3 4 (7 3 .9 )
1 2 (2 6 .1 )
A ra b s in
U S A
N /A
T h e A si an
A m e ri ca n M u lt id im e n si o n al A cc u lt u ra ti o n
S ca le 7 3
8 -I te m s M o ri sk y M e d ic at io n
A d h e re n ce
S ca le 5 1
W an n as ir ik u l e t al ,
2 0 1 6 ,3 9 T h ai la n d
H T N
6 0 – 7 0
1 4 5 (2 4 .2 )
4 5 5 (7 5 .8 )
E ld e rl y p at ie n ts
in S a
K ae o in
T h ai la n d
7 .2
F u n ct io n al , co m m u n ic at iv e an d cr it ic al h e al th
lit -
e ra cy
sc al e 7 4
A d h e re n ce
to R e fi lls
an d
M e d ic at io n s S ca le 7 1
A b b re vi at io n s:
D M T 2 , ty p e 2 d ia b e te s m e lli tu s; H T N , h yp e rt e n si o n ; N /A , n o t av ai la b le .
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in the USA found that those with high level of acculturation
were most likely to be adherent to antihypertensive
medications.28 Four cultural factors, lower perceived sus-
ceptibility in general, higher perceived benefits of Chinese
herbs, lower perceived benefits of Western medications and
a longer duration of residence in the Western country
investigated in another study, were associated with medica-
tion non-adherence in the case of hypertension. Chinese
immigrants who believed that hypertension had an influence
on their personal lives (perceived susceptibility in general)
were more compliant with anti-hypertensive medications
(Table 3).27 Another study investigated Asian patients’
E lig
ib ili
ty
Records screened on title and abstract
(n=1673)
Id en
tif ic
at io
n In
cl ud
ed
Full-text articles assessed for eligibility
(n=127)
Databases (n=2642) ● PubMed (n=1155) ● CINAHL (n=485) ● PsycINFO (n=373) ● Embase (n=629)
Duplicates removed
(n=937) Excluded: (n=1582)
● Not peer reviewed articles: n= 468
● Study population did not consist of adults: n=491
● Other languages: n=79 ● Article did not address one
of the included chronic conditions: n=417
● Articles addressing adherence and text messaging: n=127
Identified through reference lists and hand searching
(n=4)
Studies included in review
(n=25)
gnineerc S
Excluded: (n=102)
● Article addressed medication or treatment beliefs: n= 39
● Study population consist of healthy participants: n=9
● Article did not measure the association between medication adherence and the included beliefs: n= 53
● Article used unclear method to measure beliefs: n=1
Figure 1 PRISMA flow chart of the literature search and study selection.
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asthmatic perceptions, behaviors and the association with
medication adherence in China, Korea, Malaysia, Taiwan,
Thailand and Vietnam. Patients with low adherence were
more likely to believe that using traditional herbal medi-
cines is safer than inhalers.37
Religious/spiritual beliefs
Four studies examined religious beliefs,7,13,31,33 and two
mentioned the contribution of spiritual beliefs to medica-
tion adherence and self-management (Table 3).7,13
Two studies conducted in the Middle-East examined the
role of the Islamic religion.31,33 A study carried out in Saudi
Arabia found that people who reported that they can follow
their medication regimen, and perceived that God controls
their health and illness, were found to have good adherence
to taking their medication33 (Table 3). The most common
perceived cause of DMT2 in a Libyan study was found to be
Allah’s will (86.6%).31 In a study from Ghana, hypertensive
patients, 90% of whomwere Christians, exhibited high levels
of both spirituality and religiosity. However, spirituality, not
religiosity, was associated significantly with medication non-
adherence (Table 3). The authors suggested that some
patients would risk not taking their medications while antici-
pating divine healing outcomes.7 Another study carried out in
the USA, focusing on Christian black women, found that
attending church, praying and reading Bible/religious mate-
rial, and having strong spiritual beliefs were not significantly
associated with medication adherence13 (Table 3).
Knowledge and personal perceptions about illness
Five studies examined the concept of illness knowledge and
personal perceptions of chronic illnesses (Table 3).24,35–38 In
a study that illuminated patients’ perceptions of asthma
management as well as the current status of asthma control
and adherence in the participating Asian countries, adher-
ence was significantly associated with patients’ self-reported
understanding of asthma, inhaler techniques and with
patients’ acceptance of inhaler medicines in terms of bene-
fits, safety, convenience and cost. Better adherence was
associated with better understanding of the disease.37 In
line with these findings, two of the studies that focused on
DMT2,35,36 and one focused on HTN38 reported that having
the essential knowledge about the condition and the care for
the condition was associated with a higher level of confi-
dence of people with illness in their ability to perform self-
care and medication adherence (Table 3).
In contrast to previous findings related to knowledge and
adherence, a study which examined the relationship between
emotional coping and DMT2 knowledge, medication adher-
ence and self-care behaviors in adults with DMT2 identified
no significant associations with medication adherence and
DMT2 knowledge. However, being active in communicating
the emotional experience was positively related to self-care
behaviors, and negatively with medication adherence.24
Self-efficacy
Perceived self-efficacy was the lone significant factor iden-
tified to be common among four self-care management
behaviors (diet, medication adherence, health care provider
consultation and exercise) in a study that measured factors
potentially associated with self-management practices of
people with DMT2.35 The significant association between
self-efficacy and adherence was also mentioned in two other
studies that examined health literacy in patients with
DMT2. Self-efficacy was found to be correlated positively
with medication adherence (Table 4).16,26
Health literacy
Four studies illustrated the impact of health literacy on
medication adherence (Table 4).16,18,26,39 In two studies,
health literacy was found to have no direct association with
medication adherence,16,26 but it had a significant moderator
effect on the relationship between adherence and medication
concerns and illness perceptions in one study.26 However, in
two studies, health literacy was found to have a direct effect
as well as indirect effect on adherence, mediated by medica-
tion concerns in one study,18 and cognitive ability or literacy
in the second one39 (Table 4). Across all health literacy
levels, there was a significant negative association between
threatening illness perceptions and medication adherence.
For individuals with low and moderate health literacy,
increased levels of threatening illness perceptions resulted
in a sharp decline in medication adherence.18,26
Discussion The findings of the majority of research papers included in
this systematic review have demonstrated a significant rela-
tionship between illness perceptions and other beliefs and
medication adherence, in patients with the selected chronic
conditions. However, the direction of associations was not
consistent amongst studies. Figure 2 presents a conceptual
framework which has been adapted from two studies,26,30
and modified by the authors, to identify the associations of
negative illness representation, the cause of illness, religios-
ity and cultural beliefs, and beliefs with regard to the control,
self-efficacy and knowledge of medication adherence as
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identified in this review. We have also included the mediat-
ing effects of health literacy. Although this framework is not
presenting the relationships of mediating effects between
these beliefs, in fact these may exist.
Control of illness was the most significant predictor of
a favorable outcome;30 patients who believed in their own
ability to control illness, and had strong confidence in
treatment reported better medication adherence in many
studies.4,25,29–31 Although one study reported a negative
association between patients’ beliefs about their control of
illnesses and medication adherence,3 this discrepancy may
be attributed to the fact that patients of this study had high
numbers of symptoms and negative emotional responses
towards their illness. Different characteristics of the sam-
ples, such as household incomes, educational levels or
locus of control may have contributed as well; however,
these were not reported.
Perception of a lower ability to control a health threat
may imply an ineffectiveness of one’s behavioral actions,
or cognitive and emotional changes in illness representa-
tions because of somatic experiences. Higher control is
associated with lower anxiety, lower avoidance/denial of
coping strategies and positive reappraisal.30
Illness perceptions are influenced by somatic and
symptomatic information that patients receive from health
care professionals and the satisfaction with the information
received. Once patients report symptoms after a diagnosis,
inconsistency between symptom attributions of patients
and health professionals may arise. Eventually, patients
may adopt the perspective of professionals, but they will
continue to try to understand their symptom experience
based on personal perceptions, not the illness entity, and
create more barriers to adherence to therapeutic
regimens.29 Therefore, it is important prior to and during
treatment to assess patients’ views about their illness,
symptoms, treatments and also their satisfaction with
information received.41
Although two studies found no association between
medication adherence and illness symptoms,5,29
a number of points may explain this inconsistency; the
high educational level of the participants, and the fairly
stable disease progression among patients who have
long history of illness (diagnosed for more than 10
years). Evidence from the literature demonstrates that
newly diagnosed patients with illness were more likely
to drop out of treatment if they perceived the disease to
be acute or experienced symptoms upon their first clin-
ical visit.30 Additionally, adherence to medication is
related to the particular condition. An asymptomatic
nature of a disease, as well as clinical improvement,
reduces patient motivation to take medications as
prescribed.8
Figure 2 Conceptual model to illustrate the effect of illness perceptions and other beliefs on medication adherences.
Note: Data from these studies.26,30
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Other beliefs such as spiritual, religious and cultural
beliefs were demonstrated in this systematic review to
have a significant effect on medication adherence.
Spirituality and religiosity are increasingly identified as
impacting health and treatment.7 Cultural influences
may have direct impact on patient’s adherence via per-
ceptions of health and disease management. The health
beliefs and cultural values of the culturally and linguis-
tically diverse populations may differ from Western
medical beliefs.40
Individuals vary within a group in their acculturation
strategies (both their attitudes and actual behaviors) lead-
ing to variable behavioral repertoires. Thus, from this
perspective, there is no expectation of one single accul-
turation pattern, but of highly variable strategies and out-
comes that lead to variably successful long-term
adaptations.42
Factors that contributed to medication adherence can
be classified as modifiable and non-modifiable factors.
Age, gender and ethnicity are some of the non-
modifiable factors that can affect medication adherence.
Personal and cultural beliefs discussed above are difficult
to modify in patients who have chronic illnesses; however,
these patients are amendable to counseling by health care
providers; hence, patients’ perceptions of their illness
should be a target for intervention to enhance adherence
to medications.
Patient trust in physicians is another modifiable factor,
and an important facilitator of self-efficacy, and plays an
important role in a patient’s ability to maintain medication
adherence.43 Physician communication training focused on
positive and empathic communication can improve patient
satisfaction, adherence and trust.44
Several clinical implications can be drawn from this
systematic review. Understanding patients’ pre-existing
perceptions of illness before giving new information is
required. In this way, health care professionals and patients
have the opportunity to recognize gaps, confusions and
misconceptions in the patient’s perceptions.41 In addition,
patients need to be educated about their illness, symptoms
and medications. Health care providers play a major role
in that regard, and a collaborative care approach can
facilitate the education of patients about the benefits of
medications and the importance of their continuous use.36
Health care providers should take into account the impact
of religious and cultural background on health beliefs to
provide sensitive care to diverse ethnic populations to
achieve better medication adherence.
We also suggest that patients with negative illness
perceptions and low health literacy may benefit from prac-
tical interventions, such as psycho-educational and cogni-
tive-behavioral interventions. Interventions focusing on
illness perceptions should first consider the individuals’
numeracy skills by assessing in clinical settings, how
well patients understand the implications of their blood
sugar measurements, blood pressure results and practical-
ities of medication dosing, etc. Understanding the patients’
numeracy skills will then allow for a more tailored
approach to using simple and plain language to commu-
nicate their treatment during counseling.26
To improve comprehension and subsequent adherence,
techniques should be tailored to the patient and context and
may include using familiar language and pictures, contextua-
lizing facts and behaviors, or providing audio or print
materials.18
Poorer medication adherence in less acculturated
patients might relate to their traditional health beliefs as
well as ineffective communication with health care provi-
ders due to language barriers.40 We suggest that migrant
patients need to learn the language of countries in which
they resettle. In addition, migrants may often be best able
to integrate themselves into the receiving society when
they receive help, encouragement and tangible support
resources from members of the local community.45
Non-adherence should not be perceived as only the
patients’ responsibility. On the contrary, social factors
(such as social support, economic factors, etc.), health
care-related factors (eg, barriers to health care and quality
of provider–patient communication), condition character-
istics, as well as therapy-related factors (such as patient
friendliness of the therapy) play an important role in
addressing adherence.8
Limitations There were some limitations in the current review; some of
the selected studies in this review used self-reports method to
measure adherence, different tools were used to measure
beliefs and also most of studies participants were recruited
from a small geographic region, so findings of these studies
may not be generalizable. A particular strength of the present
review was our inclusiveness. We extended the previous
review by examining illness perception according to the
common-sense model, included the impact of knowledge,
religiosity and spirituality, in a number of the most prevalent
chronic conditions. In addition, we excluded the studies with
insufficient methodological details.
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Conclusion This review showed a significant positive or negative
association between personal and cultural beliefs and med-
ication adherence. Illness perceptions and other beliefs
may influence the actions of the individual and negatively
or positively affect his or her health and taking medication.
This review draws attention to enhancing medication
adherence amongst chronically ill patients, by changing
their beliefs, illness perceptions and managing their nega-
tive emotional responses, and also gives an insight to the
need for additional studies related to the impact of perso-
nal beliefs, acculturation and religion, on medication
adherence to clarify the unexpected direction of associa-
tion on medication adherence. In addition, this review
highlights the gap in literature regarding studies which
investigated the impact of different beliefs on medication
adherence for patients diagnosed with COPD and/or
asthma.
Health care providers need to understand the impact of
illness perceptions, cultural and other beliefs on patients’
adherence levels so that they can implement appropriate
strategies to enhance adherence.
Disclosure The authors report no conflicts of interest in this work.
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