Validation of the Arabic Version of General Medication Adherence Scale (GMAS) in Sudanese Patients with Diabetes Mellitus

Medication adherence scales in non-communicable diseases: A scoping review of design gaps, constructs and validation processes

INTRODUCTION

NCDs arise from complex interactions of modifiable factors such as unhealthy lifestyles, poor diet, and psychosocial challenges, along with non-modifiable factors like age and genetics. Notably, medication non-adherence is a widespread and growing concern, significantly contributing to disease progression and poor outcomes globally.

OBJECTIVE

This scoping review aims to synthesize evidence on medication adherence scales used for selected non communicable diseases. It examines their development methods, psychometric properties, and assessed domains, while identifying gaps or limitations in their design and application.

MATERIALS AND METHODS

The Joanna Briggs Institute methodological framework guided this scoping review and the protocol was registered prospectively to ensure methodological transparency and rigor. Electronic databases, the reference list of included articles, and grey literature were searched. Studies published in English from January 1950 to June 2024 were included. Two reviewers independently screened all articles, and a third reviewer settled any conflicts between the reviewers. Critical appraisal of the screened-in articles was done using JBI critical appraisal scales. The data was compiled into tables and a narrative summary that is consistent with the review's goal.

RESULTS

Our study included 140 articles, identifying 57 medication adherence scales. These scales, developed using qualitative methods (10.8%), literature review (32.4%), and mixed methods (45.9%), primarily focus on behavior, often neglecting cost-related non-adherence, self-efficacy, and systemic barriers. Psychometric findings varied widely, reflecting heterogeneity in study designs and scale development approaches. Many scales lack validation in diverse settings, underscoring the need for comprehensive, context-sensitive tools.

CONCLUSION

This scoping review highlights gaps in existing medication adherence scales for NCDs, particularly their limited consideration of socioeconomic and cultural factors and incomplete adherence assessment. Future research should focus on developing more holistic, contextually relevant adherence scales that integrate these dimensions. Strengthening adherence measurement methodologies can enhance patient-centered care, inform policy interventions, and improve health outcomes.

Arabic translation and cultural adaptation of Hill-Bone compliance to high blood pressure therapy scale

Background

Adherence to prescription medications is vital to the success of any treatment plan, especially for chronic health conditions, such as hypertension (HTN). Although there are different scales used in assessing adherence to prescription medications, most if not all, of those scales are not available in Arabic. The absence of essential assessment tools makes the appraisal of adherence to prescription medications very difficult for native Arabic speakers. Therefore, this study aimed to translate and validate the Hill-Bone Compliance to High Blood Pressure Therapy (CHBPT) scale, which is commonly used to assess adherence to antihypertensive medications, among a sample of Arabic-speaking patients with HTN.

Methods

This was a single-center cross-sectional study that took place at a university-affiliated hospital. It interviewed adult (≥18 years) patients with HTN who were visiting the primary care clinics between January and November 2020. Non-Arabic speakers, those under 18 years of age, individuals without a diagnosis of HTN, and patients without any previously filled prescription medications for HTN within the past three months were excluded. The forward-backward translation method was used after receiving permission from the originators of the questionnaire to translate their scale to Arabic. Test-retest and Cronbach alpha methods were used to assess the reliability. Principal component analysis with varimax rotation was used to examine the construct validity.

Results

One hundred and forty-one patients consented and participated in the study. Most of the patients were ≥ 50 years old (75 %), male (72 %), and had another chronic health condition besides HTN (99 %). The translated scale had good internal consistency (Cronbach alpha = 0.83) and reliability (intraclass correlation coefficient of 0.9). The Kaiser-Meyer-Oklin was 0.82 indicating adequate sampling to conduct factor analysis; hence, three factors (e.g., subscales) were extracted similar to the original scale. The mean scores for appointment keeping, medication taking, and reducing sodium intake subscales, as well as for the overall scale were 5.62 ± 1.39, 33.94 ± 3.87, 9.73 ± 2.1, and 49.29 ± 5.21, respectively.

Conclusion

The translated version of the Hill-Bone CHBPT scale has both good reliability and validity and will hopefully help healthcare providers assess and monitor HTN patients' adherence to their antihypertensive medication regimens. Multicenter studies should be conducted to verify the validity and reliability of the translated questionnaire among different Arabic-speaking patient populations with HTN.

Quality of measurement properties of medication adherence instruments in cardiovascular diseases and type 2 diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

Medication adherence has a major impact on reducing mortality and healthcare costs related to the treatment of cardiovascular diseases and diabetes mellitus. Selecting the best patient-reported outcome measure (PROM) among the many available for this kind of patient is extremely important. This study aims to critically assess, compare and synthesize the quality of the measurement properties of patient-reported outcome measures to assess medication adherence among patients with cardiovascular diseases and/or type 2 diabetes mellitus.

METHODS

This review followed the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines and was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). The searches were performed in Web of Science, SCOPUS, PubMed, CINAHL, EMBASE, LILACS, PsycINFO, and ProQuest (gray literature).

RESULTS

A total of 110 records encompassing 27 different PROMs were included in the review. The included records were published between 1986 and 2023, most of which reported studies conducted in the United States and were published in English. None of the PROMs were classified in the category "a", thus being recommended for use due to the quality of its measurement properties. The PROMs that should not be recommended for use (category "c") are the MTA, GMAS, DMAS-7, MALMAS, ARMS-D, and 5-item questionnaire. The remaining PROMs, e.g., MMAS-8, SMAQ, MEDS, MNPS, ARMS-12, MGT, MTA-OA, MTA-Insulin, LMAS-14, MARS-5, A-14, ARMS-10, IADMAS, MAQ, MMAS-5, ProMAS, ARMS-7, 3-item questionnaire, AS, 12-item questionnaire, and Mascard were considered as having the potential to be recommended for use (category "b").

CONCLUSION

None of the included PROMs met the criteria for being classified as trusted and recommended for use for patients with cardiovascular diseases and/or type 2 diabetes mellitus. However, 21 PROMs have the potential to be recommended for use, but further studies are needed to ensure their quality based on the COSMIN guideline for systematic reviews of PROMs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019129109.

Translation and validation of the Sindhi version of the general medication adherence scale in patients with chronic diseases

Background: There is no medication adherence scale available in Sindhi language currently. Hence, the Sindhi speaking population will either use a translator or provide their medical history in another language for documentation of medical conditions. This poses a challenge in monitoring and evaluating adherence to medications within this linguistic community. Aim: The aim of this study was to translate and validate the Sindhi version of the General Medication Adherence Scale (GMAS-S) in patients with chronic diseases. Methods: This was a cross-sectional study of 4 months duration and was conducted in out-patient department of a university affiliated hospital in Karachi, Pakistan. All adults with chronic diseases, who were on long-term medications, and able to read and understand Sindhi language were invited. Convenience sampling was employed and a questionnaire consisting of demographic questions and the Sindhi version of GMAS was used. The translation of the scale was carried out. Confirmatory factor analysis (CFA) was conducted, and a structural equation model (SEM) was developed. Fit indices, namely, goodness of fit index (GFI), adjusted goodness of fit index (AGFI), Tucker Lewis index (TLI), comparative fit index (CFI), and root mean square error of approximation (RMSEA) were reported. Reliability was assessed using Cronbach's alpha (α), intraclass correlation coefficient (ICC), corrected item-to-total correlation (ITC) and item deletion. Data were analysed through IBM SPSS version 23 and IBM AMOS version 25. The study obtained ethical clearance. Results: A total of 150 responses were analysed. The reliability of the Sindhi version of GMAS was (α) = 0.696. The intraclass correlation coefficient (ICC) was reported at 0.696 (95% CI: 0.618-0.763). The values for the fit indices were as follows: χ2/df = 1.84, GFI = 0.918, TLI = 0.920, CFI = 0.942, AGFI = 0.864, and RMSEA = 0.075. All values except AGFI were in the acceptable ranges and indicated good fitness. Most participants (80.7%) appeared non-adherent to their medications. Conclusion: The results of the study demonstrate that the Sindhi version of the GMAS is a valid and reliable scale to measure adherence in Sindhi speaking persons with chronic diseases.

Validation of the Arabic version of the general medication adherence scale in patients with type 2 diabetes mellitus in Jordan

Background: Medication adherence is a major challenge for patients with diabetes. Adherence rates are often low, and this can lead to poor glycaemic control and increased risk of complications. There are a number of tools available to measure medication adherence, but few have been validated in Arabic-speaking populations. Aim: This study aimed to validate the Arabic version of the General Medication Adherence Scale in patients with type 2 diabetes in Jordan. Methods: A cross-sectional study was conducted for 3 months among patients attending diabetes mellitus outpatient clinic in Irbid, Jordan. The validation procedure included confirmatory factor analysis (CFA) and equation modelling (SEM). Fit indices, namely, goodness of fit index (GFI), Tucker Lewis index (TLI), comparative fit index (CFI), and root mean square error of approximation (RMSEA) were observed. Corrected item-total correlation (ITC) was reported. Reliability was assessed using Cronbach's alpha (α) and α value based on item deletion was also carried out. Intraclass correlation coefficient (ICC) was reported. Data were analyzed using IBM SPSS v23 and IBM AMOS v25. Results: Data from 119 participants were gathered. The mean adherence score was 27.5 (±6) ranging from 6 to 33. More than half of the patients were adherent to their therapy (n = 79, 66.4%). The reliability of the scale (n = 11) was 0.907, and ICC ranged from 0.880-0.930: 95% CI. The following values were observed in CFA; χ2 = 62.158, df = 41, χ2/df = 1.516, GFI = 0.913, AGFI = 0.860, TLI = 0.960, CFI = 0.971 and RMSEA = 0.066. A total of 10 out of 11 items had corrected ITC >0.5. The α remained between 0.89-0.92 during item deletion. Conclusion: The results obtained in this study suggest that the scale is valid and reliable in measuring adherence to medications in the studied sample of patients with diabetes. This scale can be used by clinicians in Jordan to assess adherence and may further aide in evaluating interventions to improve adherence rates in persons with type 2 diabetes.

Translation, cultural adaptation and validation of the General Medication Adherence Scale (GMAS) in moroccan patients with type-2 diabetes

BACKGROUND

The objective of the study was to cross-culturally adapt and validate the General Medication Adherence Scale (GMAS) in patients with type-2 diabetes in Morocco.

METHODS

The study was a cross-sectional study conducted between September 12 and October 12, 2022, and included patients with type-2 diabetes from a primary health care network. To measure the different psychometric parameters of the construct, data analysis was performed using SPSS v20. The study was approved by the Moroccan Association for Research and Ethics.

RESULTS

A total of 284 patients were included in the study; the results of the different psychometric parameters were largely acceptable. Indeed, the improvement of the goodness-of-fit of the model in relation to the independence model was evaluated by the comparative fit index (CFI), which was higher than 0.95, as well as the normalized fit index (NFI), which expresses the percentage of the general covariance between the variable demonstrated via the tested model when the null model is taken as reference and was also higher than 0.95 in this study. Additionally, the Tucker Louis Index (TLI) or Unstandardized Fit Index, which measures the increase in goodness of fit when moving from the reference model to the model under study, had a value of > 0.95. The correlations between the items were good; indeed, the Kaiser-Meyer-Olkin (KMO) index was > 0.7. The translated tool presents good internal consistency; thus, Cronbach's α had a value of approximately 0.804 (> 0.7).

CONCLUSIONS

The version of the GMAS tool adapted to the Moroccan context has very acceptable psychometric values. This means that Moroccan researchers and health professionals can use it as an instrument to measure adherence among individuals with type-2 diabetes.

Effect of Pharmacist-Led Interventions on Medication Adherence among Vietnamese Patients with Asthma: A Randomized Controlled Trial

BACKGROUND

Medication adherence in asthmatic patients enhances the effectiveness of treatments, but some studies in low and middle-income countries still show some limitations. Our study aimed to determine if pharmacist-led interventions could increase medication adherence, improve treatment effectiveness, and relieve symptom severity in outpatients with asthma.

METHODS

We conducted a randomized, controlled trial on 247 asthmatic outpatients (aged ≥ 16) with a 1:1 ratio randomization at the hospitalization time and repeated after 1-month discharge. The primary outcome was to detect the difference in medication adherence between groups. Adherence was assessed by the general medication adherence scale (GMAS). Data collected by questionnaire was coded and entered into SPSS_20 for statistical analysis; Results: 247 patients (123 intervention, 124 control) were enrolled (61.1% male). After intervention, the adherence rate was higher among the intervention group than the control group (94.3% vs. 82.8%, p = 0.001). Patient behavior and knowledge were enhanced in the intervention group (p < 0.05). Asthma symptoms were relieved in the intervention group (p = 0.014). Pharmacist-led interventions on adherence rate were higher with OR: 3.550, 95% CI: 1.378-9.143, p = 0.009.

CONCLUSIONS

pharmaceutical intervention could improve medication adherence, treatment efficacy, and the outcome should not be taken for granted; further research should be carried out in this regard.

Development and Evaluation of Interactive Flipped e-Learning (iFEEL) for Pharmacy Students during the COVID-19 Pandemic

Background: Distance learning has come to the forefront of educational delivery throughout the world due to the COVID-19 pandemic. Presently, there is a paucity of studies that have utilized interactive e-lectures as a model for remote flipped learning. Objectives: To compare educational outcomes for the remote interactive flipped e-learning (iFEEL) activity versus paper-based in-class group learning (PICkLE). Methods: During the spring 2021 semester, tutorials in pharmaceutical quality control and good manufacturing practice were remotely delivered to students by two different approaches: PICkLE and iFEEL. In the latter activity, interactive e-lectures were software-designed and included several audiovisual enhanced illustrations to encourage students to interact with the lecture material prior to attending the virtual class. The class time was reserved for in-class quizzes and discussion. Mean exam scores were compared and voluntary questionnaires were distributed among the participating students as well as healthcare faculty members in 29 Saudi universities. Data from the remotely-delivered course was compared with data from previous course offerings (2018−2020) that used the live PICkLE method. Results: The mean score of post-lecture tests significantly (p < 0.05) increased compared to pre-lecture tests in remote PICkLE and iFEEL, respectively. iFEEL activity showed higher mean post-tests score (95.2%) compared to live PICkLE (90.2%, p = 0.08) and remote PICkLE (93.5%, p = 0.658). Mean comprehensive exam scores increased from 83.8% for remote PICkLE to 89.2% for iFEEL (p = 0.449). On average, 92% of students and 85% of faculty members reported positive feedback on the five quality attributes of the e-lecture. Over 75% of students preferred the iFEEL over PICkLE activity for future course offerings and 84% of faculty members recommend the integration of interactive e-lectures in their future courses. Conclusion: iFEEL represents a novel model of remote flipped learning and shows promising potential to be incorporated into live blended-learning classroom activities.