The impact of personal and cultural beliefs on medication adherence of patients with chronic illnesses: a systematic review

Figures & data

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 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: 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

Table 2 Summary of associations between illness perceptions and medication adherence

Study	Association between illness perceptions and medication adherence
Chen et al, 2011^Citation30	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, 2015^Citation31	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, 2009^Citation29	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 consequences (β= −0.12, p<0.05).
Mann et al, 2009^Citation4	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, 2014^Citation11	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, 2012^Citation3	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, 2016^Citation32	No significant association between illness perceptions and medication adherence (p=0.52, OR=1.0, CI=0.9–1.0).
Krauskopf et al, 2015^Citation5	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, 2014^Citation25	Positive association between threatening perceived illness burden and medication adherence (r=0.332, p<0.001).
Aflakseir, 2012^Citation34	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).

Table 3 Association of other factors and beliefs on medication adherence

Study	Religious beliefs	Cultural beliefs	Illness knowledge/personal perceptions
Eh et al, 2016^Citation40		Negative association between strong beliefs in the superiority of traditional Chinese medicines and medication adherence (β=−0.19, p=0.02). Positive correlation between acculturation and medication adherence β=0.25, p=0.004)
Li et al, 2006^Citation27		Negative association between susceptibility and medication adherence (OR=3.77, 95% CI 1.19–12.01). Negative association between strong beliefs in the superiority of Chinese herbs and medication adherence (OR=2.2, 95% CI=1.02–4.81). Negative association between lower perceived benefit of Western medications for hypertension and medication adherence (OR=2.78, 95% CI=1.13–6.84). Negative association between longer length of stay in the United States and medication adherence (OR=2.48, 95% CI=1.12–5.50)
Chiu et al, 2014^Citation37		Negative association between using traditional herbal medicines and medication adherence	Significant positive association between patients’ understanding of the disease and medication adherence (p<0.01)
Albargawi et al, 2017^Citation33	Significant positive association between religious beliefs and medication adherence (p=0.04)
Kretchy et al, 2013^Citation7	Spiritual beliefs negatively associated with medication adherence (p=0.02), whereas no association with religious beliefs (p=0.47)
Nazir et al, 2016^Citation36			Positive association between patients’ knowledge about DMT2 and medication adherence (r=0.04, p<0.05)
Ku & Kegels, 2015^Citation35			Positive association between illness knowledge and self-management practices, and medication adherence (p=0.007)
Small et al, 2012^Citation24			No association between diabetic knowledge and medication adherence
Abel et al, 2017^Citation13	There was a non-significant correlation between medication adherence and the four spiritual/religious variables: Attending church/religious services (p= 0.08) Praying (p= 0.43) Reading Bible/religious material (p= 0.19) Strength of spiritual beliefs (p=0.54)
Jankowska et al, 2016^Citation38			Positive significant association between medication adherence and high level of illness knowledge (β=0.208; p=0.001).
Tailakh et al, 2016^Citation28		Acculturated participants were more adherent to medications and physical activity and had better blood pressure control.

Abbreviation: DMT2, type 2 diabetes mellitus.

Table 4 Association of health literacy and self-efficacy on medication adherence

Study	Health literacy	Self-efficacy
Ku & Kegels, 2015^Citation35		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, 2017^Citation26	No direct relationship with medication adherence; however, 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, 2017^Citation18	Directly associated positively with medication adherence (β=0.089, p<0.001) and indirectly mediated by medication concerns (β=0.03, p=0.002).
Huang et al, 2018^Citation16	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, 2016^Citation39	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)

Table 5 Measurement tools used for beliefs and medication adherence

Bibliography	Chronic condition	Demographics characteristics					Measurement of beliefs	Measurement of medication adherence
		Age (Mean)	Gender		Participants origin/cultural groups	Illness duration (mean)
			Male N (%)	Female N (%)
Krauskopf et al., 2015,5 USA	COPD	62–74	62 (33)	126 (67)	English- & Spanish-speaking patients in New York	N/A	Brief Illness Perceptions Questionnaire^Citation46 and Beliefs about Medications Questionnaire^Citation47	Medication Adherence Rating Scale (MARS)^Citation48
Hsiao et al, 2012,^Citation3 Taiwan	HTN	53.8	78 (66.7)	39 (33.3)	Taiwanese in Taiwan	N/A	Illness Perception Questionnaire – revised^Citation29	Hypertensive Patient’s Drug Adherence Questionnaire^Citation49
Saarti et al,2016,^Citation32 Lebanon	HTN	>18	59 (50.4)	58 (49.6)	Lebanese patients in Lebanon	7.8	Brief Illness Perception Questionnaire^Citation46 and Treatment Satisfaction Questionnaire for medication^Citation50	8-item Morisky Medication Adherence Scale^Citation51
Chen et al, 2011,^Citation30 Taiwan	HTN	65.2	214 (60.3)	141 (39.7)	Taiwanese patients in Taiwan (ethnic Chinese)	10.45	Illness Perception Questionnaire – Revised^Citation29	Medication Adherence Inventory and the Inventory of Adherence to Self-Management^Citation21
Ashur et al, 2015,^Citation31 Tripoli	DMT2	54.4	215 (41.1)	318 (58.9)	Libyan patients in Tripoli	9.4	Illness Perception Questionnaire – Revised^Citation29	8- Items Morisky Medication Adherence Scale^Citation51
Soones et al., 2017,^Citation18 USA	Asthma	67	70 (16.2)	363 (83.3)	Elderly patients from New York in USA	31.4	Brief Illness Perceptions Questionnaire,^Citation46 Beliefs about Medications Questionnaire^Citation4 and Short Test of Functional Health Literacy in Adults^Citation52	Medication Adherence Rating Scale (MARS)^Citation48
Chen et al, 2009,^Citation29 Taiwan	HTN	>18	166 (59.9)	111 (40.1%)	Taiwanese patients in Taiwan	10.46	Illness perception questionnaire – Revised^Citation29	Medication Adherence Inventory and the Inventory of Adherence to Self-Management^Citation21
Jacobs et al, 2014,^Citation11 USA	DMT2	54.6	20 (50)	20 (50)	Lumbi Indian tribe in USA	9.9	Illness Perceptions Questionnaire – Revised^Citation29	Morisky Medication Adherence Scale (old version)^Citation51
Rajpura & Nayak, 2014,^Citation25 USA	HTN	>55	75 (64.1)	42 (35.9)	American elderly	>7 years	Brief Illness Perception Questionnaire^Citation46 Beliefs of Medication Questionnaire^Citation47	Morisky Medication Adherence Scale (old version)^Citation51
Mann et al, 2009,^Citation4 USA	DMT2	57	49 (32)	102 (68)	English- and Spanish-speaking patients in New York/USA	13.0	Brief-Illness Perception Questionnaire^Citation46 Beliefs about Medicines Questionnaire^Citation47	Morisky Medication Adherence Scale (old version)^Citation51
Shiyanbola et al, 2017,^Citation26 USA	DMT2	58.7	74 (42.5)	100 (57.5)	American patients in USA	9.6	Beliefs in Medicines Questionnaire,^Citation47 Brief-Illness Perceptions Questionnaire^Citation46 and Newest Vital Sign^Citation53	8- Items Morisky Medication Adherence Scale^Citation51
Ku & Kegels, 2015,^Citation35 Philippines	DMT2	62.8	227 (41.3)	322 (58.7)	Filipino patient in Philippines	7.0	Brief Diabetes Knowledge Test, the Diabetes Knowledge Questionnaire, and Diabetes Care Profile survey questionnaire^Citation54^–^Citation56	Medical records review
Nazir et al, 2016,^Citation36 Pakistan	DMT2	50.8	222 (56.6)	170 (43.4)	Pakistani patients in Pakistan	5.58	Michigan Diabetes Knowledge Test^Citation57	Urdu version of Morisky Medication Adherence Scale^Citation58
Chiu et al, 2014,^Citation37 Asia	Asthma	53.0	402 (38.2)	651 (61.8)	Asian patients in China, Korea, Malaysia, Taiwan, Thailand and Vietnam	11.4	Asthma Control Test, and the Standardized Asthma (AQLQ-S)^Citation59 Quality of Life Questionnaire^Citation60	8-Items Morisky Medication Adherence Scale^Citation51
Small et al, 2012,^Citation24 USA	DMT2	>18	261 (69.1)	116 (30.9)	English-speaking patients in southeastern United State	N/A	Diabetes Knowledge Questionnaire^Citation55	Morisky Adherence Scale (old version)^Citation61
Albargawi et al, 2017,^Citation33 Kingdom of Saudi Arabia	DMT2	49	18 (60)	12 (40)	Saudi patients in KSA	N/A	Arabic version of form C of the multidimensional health locus of control scale^Citation62	The Arabic version of the revised and expanded summary of diabetes self-care activities scale^Citation62
Eh et al, 2016,^Citation40 Australia	DMT2	62.9	62 (44.6)	77 (55.4)	Chinese in Australia	12.5	Level of acculturation.^Citation63 Beliefs in TCM and Western medicine; Chinese health beliefs^Citation64	Chinese version of Morisky Medication Adherence Scale^Citation65
Kretchy et al, 2013,^Citation7 Ghana	HTN	57.10	74 (37.25)	125 (62.75)	Ghanaian patients in Ghana	≤10	Spiritual Perspective Scale^Citation66 and Duke Religion Index^Citation67	8-Items Morisky Medication Adherence Scale^Citation51
Li et al, 2006,^Citation43 USA	HTN	70.6	100 (50)	100 (50)	White American VS African American in USA	N/A	Four-item instrument that assessed each dimension of Hall’s framework of patient trust in the physician^Citation68	Self-reported (Patients were asked to respond to a single question)
Abel et al,0.2017,^Citation13 USA	HTN	19–60	–	80 (100)	Black women in USA	N/A	Nine spiritual/religious questions developed by the investigator^Citation69	14-item Hill-Bone Compliance to High Blood Pressure Therapy scale^Citation70
Aflakseir, 2012,^Citation34 Iran	DMT2	40.7	22 (22)	78 (78)	Iranian patients in Iran	9.5	Illness perception questionnaire – Revised^Citation29	Medication Adherence Rating Scale^Citation48
Huang et al, 2018,^Citation16 USA	DMT2	58.7	74 (42.5)	100 (57.5)	English-speaking patients in a Midwestern state in USA	9.6	Newest Vital Sign^Citation53 and Self-Efficacy for Appropriate Medication Use Scale^Citation71	8-Items Morisky Medication Adherence Scale^Citation51
Jankowska et al, 2016,^Citation38 Poland	HTN	32–90	109 (46.8)	124 (53.2)	Poland patients in Poland	11.75	Hypertension Knowledge Level Scale^Citation72	8-Items Morisky Medication Adherence Scale^Citation51
Tailakh et al, 2016,^Citation28 USA	HTN	29–74	34 (73.9)	12 (26.1)	Arabs in USA	N/A	The Asian American Multidimensional Acculturation Scale^Citation73	8-Items Morisky Medication Adherence Scale^Citation51
Wannasirikul et al, 2016,^Citation39 Thailand	HTN	60–70	145 (24.2)	455 (75.8)	Elderly patients in Sa Kaeo in Thailand	7.2	Functional, communicative and critical health literacy scale^Citation74	Adherence to Refills and Medications Scale^Citation71

Abbreviations: DMT2, type 2 diabetes mellitus; HTN, hypertension; N/A, not available.

Figure 1 PRISMA flow chart of the literature search and study selection.

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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