Iran Journal of Nursing

Introduction
Diabetes is one of the most common chronic diseases, which is associated with many complications. It increases the economic burden and medical costs for individuals, families, and society. For preventing the complications of diabetes and its successful control, the patient’s participation in the treatment process and adherence to the treatment regimen is necessary. Adherence to a treatment regimen for diabetes is a complex process that includes lifestyle changes in diet, exercise, blood sugar monitoring, and taking medications. Despite the importance of adherence to the treatment regimen, adherence is not done completely. Non-adherence to treatment has many personal and social consequences. Adherence in diabetic patients can lead to mortality reduction and success in the treatment of diabetes. Considering that adherence to the treatment regimen is challenging among diabetic patients and less attention has been paid to it in Iran, the present study aims to identify the factors related to adherence to the treatment regimen among diabetic patients in Sari, Iran.
Materials and Methods
This descriptive cross-sectional study was conducted from January to May 2021 on 226 adults with Type 2 diabetes referred to a clinic affiliated to Mazandaran University of Medical Sciences in Sari, Iran who were selected using a continuous sampling method and based on inclusion criteria (age 18-65 years, reading and writing literacy, no pregnancy, no psychiatric disorder, no severe visual or hearing impairment). Data were collected using a demographic form (surveying the participants’ age, sex, educational level, marital status, occupation, economic status, lifestyle, type of duration of diagnosis, BMI, and used medications) and the diabetes activities questionnaire (TDAQ) to measure adherence to treatment regimen. Questionnaires were prepared online using Google Forms. The links were sent to the participants on WhatsApp or Telegram. Data analysis was performed in SPSS software, version 26 using descriptive statistics (frequency, Mean±SD) and inferential statistics (independent t-test, analysis of variance, Pearson correlation test).
Results 
The mean age of participants was 53.06±10.81 years. Most of them were female (61.9%), married (85.8%), with a high school diploma (26.5%) and moderate economic status (69%), and housekeepers (45.1%). Their BMI was 29.14±5.55. The mean total score of TDAQ was 903.71±259.64 ranged 20-1300. The results of one-way ANOVA showed that economic status had a significant relationship with adherence to treatment regimen (F =4.35, P= 0.01). The results of Pearson correlation test showed a significant positive relationship between adherence and age (r=0.13, P=0.04) and a significant negative relationship between adherence and BMI (r=-0.17, P=0.01). Diabetic patients with better economic status, higher age, and lower BMI had better adherence. Sex, occupation, marital status, educational level, and duration of diabetes had no significant relationship with adherence to treatment regimen.
Discussion
According to the results of the present study, it is necessary for healthcare providers, especially nurses, to pay attention to the factors related to adherence to treatment in diabetic patients in providing care and education to them to have better treatment. This study provides a basis for expanding knowledge of adherence to treatment regimens in diabetic patients in Iran. Considering that adherence to treatment regimen is significantly related to the patients’ economic status, policymakers are recommended to provide better conditions for adherence by reducing treatment costs and increasing the patients’ access to services.

Ethical Considerations
Compliance with ethical guidelines
This study obtained its ethical approval from the ethics committee of Iran University of Medical Sciences (Code: IR.IUMS.REC.1399.1009). All ethical principles were considered in this study. Informed consent was obtained from the participants, They were also assured about the confidentiality of their information and were free to leave the study at any time. If desired, the research results would be available to them.

Funding
This study was extracted from Mehrnegar Amiri's master's degree thesis in internal surgery at the Faculty of Nursing and Midwifery, Iran University of Medical Sciences and Health Services.

Authors' contributions
Supervision, project administration, funding acquisition, and preparation of the initial draft: Alice Khachian; conceptualization, preparation of the initial draft, data collection, editing & reciew: Mehrnegar Amiri; design and preparation of the initial draft: Naima Seyedfatemi; data analysis and interpretation: Hamid Sharif Nia; final approval: All authors. 

Conflict of interest
The authors declared no conflict of interest

Acknowledgments
The authors would like to thank all participants, the deputy for research of Iran University of Medical Sciences and Mazandaran University of Medical Sciences, and the staff of Baghban Clinic for their cooperation.

References

1. Mirmahdi SR, Razaali M. [The effectiveness of mindfulness-based cognitive therapy on resilince, emotion regulation and life expectancy among women with diabetes2 (Persian)]. Q J Health Psychol. 2019; 7(28):167-83. [DOI:10.30473/HPJ.2019.40990.4049]
2. International Diabetes Federation. Understanding diabetes. Brussels: International Diabetes Federation; 2020. [Link]
3. Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract. 2014; 103(2):137-49. [DOI:10.1016/j.diabres.2013.11.002] [PMID]
4. Esteghamati A, Larijani B, Aghajani MH, Ghaemi F, Kermanchi J, Shahrami A, et al. Diabetes in Iran: Prospective analysis from first nationwide diabetes report of national program for prevention and control of diabetes (NPPCD-2016). Sci Rep. 2017; 7(1):13461. [DOI:10.1038/s41598-017-13379-z] [PMID] [PMCID]
5. Esteghamati A, Ismail-Beigi F, Khaloo P, Moosaie F, Alemi H, Mansournia MA, et al. Determinants of glycemic control: Phase 2 analysis from nationwide diabetes report of national program for prevention and control of diabetes (NPPCD-2018). Prim Care Diabetes. 2020; 14(3):222-31. [DOI:10.1016/j.pcd.2019.07.002] [PMID]
6. Bayat Asgari A, Mossanejad S, Asgari M, Ramazani Farani A, Javaheri J. [The relationship between coping styles with adherence in type 2 diabetic patients (Persian)]. Iran J Diabetes Metab. 2015; 14(2):93-8. [Link]
7. Mousavizadeh SN, Ashktorab T, Ahmadi F, Zandi M. [Evaluation of barriers to adherence to therapy in patients with diabetes (Persian)]. J Diabetes Nurs. 2016; 4(3):94-108. [Link]
8. García-Pérez LE, Alvarez M, Dilla T, Gil-Guillén V, Orozco-Beltrán D. Adherence to therapies in patients with type 2 diabetes. Diabetes Ther. 2013; 4(2):175-94. [DOI:10.1007/s13300-013-0034-y] [PMID] [PMCID]
9. Mikaili N, Ghasemi MA, Salari S, Sakeni Z. [Theoretical and practical dimensions of adherence to treatment in patients: A review study (Perisan)]. Med J Mashhad Univ Med Sci. 2019; 62(2):1403-19. [Link]
10. Al-Majed HT, Ismael AE, Al-Khatlan HM, El-Shazly MK. Adherence of type-2 diabetic patients to treatment. Kuwait Med J. 2014; 46(3):225-32. [Link]
11. Mirghani HO. An evaluation of adherence to anti-diabetic medications among type 2 diabetic patients in a Sudanese outpatient clinic. Pan Afr Med J. 2019; 34:34.[DOI:10.11604/pamj.2019.34.34.15161]
12. Istilli PT, Pereira MCA, Teixeira CDS, Zanetti ML, Becker TAC, Marques JVP. Treatment adherence to oral glucose-lowering agents in people with diabetes: Using the brief medication questionnaire. J Diabetes Nurs. 2015; 19(9):340-8. [Link]
13. Moradi M, Salarfard M, Abedian Z, Mazloum SR, Mousa Farkhani E. [The relationship between underlying factors and treatment adherence in women with gestational diabetes (Persian)]. J Arak Univ Med Sci. 2020; 23(6):828-39. [DOI:10.32598/jams.23.6.6192.1]
14. Albuquerque C, Correia C, Ferreira M. Adherence to the therapeutic regime in person with type 2 diabetes. Procedia Soc Behav Sci. 2015; 171:350-8. [DOI:10.1016/j.sbspro.2015.01.132]
15. Mashrouteh M, Khanjani N. Evaluation of oral medication adherence and its related factors in type II diabetic patients in Iran: A systematic review. Int J Diabetes Res. 2017; 6(1):24-33. [DOI:10.5923/j.diabetes.20170601.04]
16. Agofure O, Okandeji-Barry Oghenenioborue R, Odjimogho S, Meeting S. Knowledge of diabetes mellitus and adherence to treatment among patients with type-2 diabetes mellitus attending a tertiary facility in Southern Nigeria. Afr J Diabetes Med. 2020; 28(2):1-6. [Link]
17. Nazir SR, Hassali MA, Saleem F, Bashir S, Aljadhey H. Does adherence to the therapeutic regimen associate with health related quality of life: Findings from an observational study of type 2 diabetes mellitus patients in Pakistan. Pak J Pharm Sci. 2017; 30(6):2159-65. [PMID]
18. Faria HTG, Rodrigues FFL, Zanetti ML, Araújo MFMd, Damasceno MMC. Factors associated with adherence to treatment of patients with diabetes mellitus. Acta paul de enfermagem. 2013; 26(3):231-7. [DOI:10.1590/S0103-21002013000300005]
19. Kalyango JN, Owino E, Nambuya AP. Non-adherence to diabetes treatment at Mulago Hospital in Uganda: prevalence and associated factors. Afr Health Sci. 2008; 8(2):67-73. [PMID] [PMCID]
20. Cillessen L, van de Ven MO, Karremans JC. The role of trait mindfulness in quality of life and asthma control among adolescents with asthma. J Psychosom Res. 2017; 99:143-148. [DOI:10.1016/j.jpsychores.2017.06.014] [PMID]
21. Hernandez CA. The development and pilot testing of the diabetes activities questionnaire (TDAQ): An instrument to measure adherence to the diabetes regimen. Appl Nurs Res. 1997; 10(4):202-11. [DOI:10.1016/S0897-1897(97)80596-4] [PMID]
22. Settineri S, Frisone F, Merlo EM, Geraci D, Martino G. Compliance, adherence, concordance, empowerment, and self-management: Five words to manifest a relational maladjustment in diabetes. J Multidiscip Healthc. 2019; 12:299-314. [DOI:10.2147/JMDH.S193752] [PMID] [PMCID]
23. Nyirongo S, Mukwato PK, Musenge EM, Kalusopa VM. Adherence to treatment by patients with type 2 diabetes mellitus at Monze Mission Hospital, Monze, Zambia. Open J Nurs. 2021; 11(3):184-203. [DOI:10.4236/ojn.2021.113017]
24. Polonsky WH, Henry RR. Poor medication adherence in type 2 diabetes: Recognizing the scope of the problem and its key contributors. Patient Prefer Adherence. 2016; 10:1299-307. [DOI:10.2147/PPA.S106821] [PMID] [PMCID]
25. Adisa R, Olajide OO, Fakeye TO. Social support, treatment adherence and outcome among hypertensive and type 2 diabetes patients in ambulatory care settings in southwestern Nigeria. Ghana Med J. 2017; 51(2):64-77. [PMID] [PMCID]
26. Krzemińska S, Lomper K, Chudiak A, Ausili D, Uchmanowicz I. The association of the level of self-care on adherence to treatment in patients diagnosed with type 2 diabetes. Acta Diabetol. 2021; 58(4):437-45. [DOI:10.1007/s00592-020-01628-z] [PMID] [PMCID]
27. Sharma T, Kalra J, Dhasmana D, Basera H. Poor adherence to treatment: A major challenge in diabetes. J Indian Acad ClinMed. 2014; 15(1):26-9. [Link]
28. Breitscheidel L, Stamenitis S, Dippel FW, Schöffski O. Economic impact of compliance to treatment with antidiabetes medication in type 2 diabetes mellitus: A review paper. J Med Econ. 2010; 13(1):8-15. [DOI:10.3111/13696990903479199] [PMID]
29. Salmoirago-Blotcher E, Carey MP. Can mindfulness training improve medication adherence? Integrative review of the current evidence and proposed conceptual model. Explore. 2018; 14(1):59-65. [DOI:10.1016/j.explore.2017.09.010] [PMID] [PMCID]
30. Tovar EG. Relationships between psychosocial factors and adherence to diet and exercise in adults with type 2 diabetes: A test of a theoretical model. [Doctoral dissertation]. Texas: University of Texas Medical Branch; 2007. [Link]
31. Rowe CA, Sirois FM, Toussaint L, Kohls N, Nöfer E, Offenbächer M, et al. Health beliefs, attitudes, and health-related quality of life in persons with fibromyalgia: mediating role of treatment adherence. Psychol Health Med. 2019; 24(8):962-77. [DOI:10.1080/13548506.2019.1576913] [PMID]
32. Alhaddad IA, Hamoui O, Hammoudeh A, Mallat S. Treatment adherence and quality of life in patients on antihypertensive medications in a Middle Eastern population: Adherence. Vasc Health Risk Manag. 2016; 12:407-13.[DOI:10.2147/VHRM.S105921] [PMID] [PMCID]
33. Perwitasari DA, Urbayatun S. Treatment adherence and quality of life in diabetes mellitus patients in Indonesia. Sage J. 2016; 6(2):1-7. [DOI:10.1177/2158244016643748]
34. Salehi Z, Norouzi Tabrizi K, Hoseini MA, Sedghi Goyaghaj N, Soltani PR. [The study of the correlation between medication adherence and quality of life of rheumatoid arthritis patients (Persian)]. J Clin Nurs Midwifery. 2017; 6(2):1-13. [Link]
35. Zioga E, Kazakos K, Dimopoulos E, Koutras C, Marmara K, Marmara EE, et al. Adherence and quality of life in patients with type II diabetes mellitus in northern greece. Mater Sociomed. 2016; 28(4):258-62. [DOI:10.5455/msm.2016.28.258-262] [PMID] [PMCID]
36. Manan MM, Husin AR, Alkhoshaiban AS, Al-Worafi YM, Ming LC. Interplay between Oral Hypoglycemic Medication Adherence and Quality of Life among Elderly Type 2 Diabetes Mellitus Patients. J Clin Diagn Res. 2014; 8(12):JC05-9. [DOI:10.7860/JCDR/2014/10481.5309] [PMID] [PMCID]
37. Buchanan A, Villani A. Association of adherence to a Mediterranean diet with excess body mass, muscle strength and physical performance in overweight or obese adults with or without type 2 diabetes: Two cross-sectional studies. Healthcare. 2021; 9(10):1255. [DOI:10.3390/healthcare9101255] [PMID] [PMCID]
38. Beernink JM, Oosterwijk MM, Khunti K, Gupta P, Patel P, van Boven JFM, et al. Biochemical urine testing of medication adherence and its association with clinical markers in an outpatient population of type 2 diabetes patients: Analysis in the diabetes and lifestyle cohort twente (DIALECT). Diabetes Care. 2021; 44(6):1419-25. [DOI:10.2337/dc20-2533] [PMID] [PMCID]
39. Marinho FS, Moram CBM, Rodrigues PC, Leite NC, Salles GF, Cardoso CRL. Treatment adherence and its associated factors in patients with type 2 diabetes: Results from the Rio de Janeiro type 2 diabetes Cohort study. J Diabetes Res. 2018; 2018:8970196. [DOI:10.1155/2018/8970196] [PMID] [PMCID]
40. Moradkhani B, Mollazadeh S, Niloofar P, Bashiri A, Oghazian MB. Association between medication adherence and health-related quality of life in patients with chronic obstructive pulmonary disease. Journal of Pharmaceutical Health Care and Sciences. 2021; 7(1):1-9. [DOI:10.1186/s40780-021-00222-x] [PMID] [PMCID]
41. Forouzan Z, Gholamrezaie A, Nasimi H, Faramarzi M, Bagheri-Ghalehsalimi A, et al. Factors associated with adherence to treatment in Iranian patients with inflammatory bowel disease. J Res Med Sci. 2021; 26:92. [DOI:10.4103/jrms.JRMS_866_16] [PMID] [PMCID]
42. Javanmardifard S, Heidari S, Sanjari M, Yazdanmehr M, Shirazi F. The relationship between spiritual well-being and hope, and adherence to treatment regimen in patients with diabetes. J Diabetes Metab Disord. 2020; 19(2):941-50. [DOI:10.1007/s40200-020-00586-1] [PMID] [PMCID]
43. Al-Rasheedi AA. The role of educational level in glycemic control among patients with type ii diabetes mellitus. Int J Health Sci. 2014; 8(2):177-87. [DOI:10.12816/0006084] [PMID] [PMCID]
44. Abedi HA, Rezaei A, Alimohammadi N, Ghodusi A, Maghroon A. [An investigation of demographic and social factors affecting compliance with therapeutic regimens in type ii diabetic patients (Persian)]. 2015; 3(2):66-81. [Link]