Abstract
Non-adherence to insulin is common and associated with suboptimal health. We adapted the Morisky Medication Adherence Scale to specify insulin adherence (MIAS) and compared it to the Adherence to Refills and Medication Scale for Diabetes (ARMS-D) and the Summary of Diabetes Self-Care Activities medications subscale (SDSCA-MS) and an insulin-specific (SDSCA-IS) version. A sample of 144 insulin-treated adults (58 % African American/Black, 34 % Caucasian/White, 8 % Other/Mixed race; 6.9 % Hispanic) completed these measures along with a HbA1C test. The internal consistency and factor structure of the MIAS were adequate; 59 % of participants forgot to take insulin and 46 % reported non-adherence. The MIAS was associated with the ARMS-D, SDSCA-MS, and SDSCA-IS (p < 0.001), and higher MIAS scores were marginally associated with better self-rated health (p = 0.057), but significantly associated with fewer emergency room visits (p = 0.001), and better HbA1C (p = 0.001). The MIAS is a valid and reliable insulin adherence assessment tool for practice and research applications.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Al-Qazaz, H., Hassali, M. A., Shafie, A. A., et al. (2010). The eight-item Morisky Medication Adherence Scale MMAS: translation and validation of the Malaysian version. Diabetes Research and Clinical Practice, 90, 216–221.
Baek, R. N., Tanenbaum, M. L., & Gonzalez, J. S. (2014). Diabetes burden and diabetes distress: the buffering effect of social support. Annals of Behavioral Medicine, 48, 145–155.
Balkrishnan, R., Rajagopalan, R., Camacho, F. T., et al. (2003). Predictors of medication adherence and associated health care costs in an older population with type 2 diabetes mellitus: a longitudinal cohort study. Clinical Therapeutics, 25, 2958–2971.
Chung, W. W., Chua, S. S., Lai, P. S., et al. (2015). The Malaysian Medication Adherence Scale (MALMAS): Concurrent validity using a clinical measure among people with type 2 diabetes in Malaysia. PLoS ONE, 10, e0124275.
Cramer, J. A. (2004). A systematic review of adherence with medications for diabetes. Diabetes Care, 27, 1218–1224.
Cramer, J. A., & Pugh, M. J. (2005). The influence of insulin use on glycemic control: How well do adults follow prescriptions for insulin? Diabetes Care, 28, 78–83.
Davies, M. J., Gagliardino, J. J., Gray, L. J., et al. (2013). Real-world factors affecting adherence to insulin therapy in patients with Type 1 or Type 2 diabetes mellitus: a systematic review. Diabetic Medicine, 30, 512–524.
DeVellis, R. (1991). Scale development. Theory and applications. Newbury Park, CA: Sage.
DiBonaventura, M., Wintfeld, N., Huang, J., et al. (2014). The association between nonadherence and glycated hemoglobin among type 2 diabetes patients using basal insulin analogs. Patient Prefer Adherence, 8, 873–882.
Driscoll, K. A., & Young-Hyman, D. (2014). Use of technology when assessing adherence to diabetes self-management behaviors. Current Diabetes Reports, 14, 521.
Egede, L. E., Gebregziabher, M., Hunt, K. J., et al. (2011). Regional, geographic, and ethnic differences in medication adherence among adults with type 2 diabetes. Annals of Pharmacotherapy, 45, 169–178.
Feldman, B. S., Cohen-Stavi, C. J., Leibowitz, M., et al. (2014). Defining the role of medication adherence in poor glycemic control among a general adult population with diabetes. PLoS ONE, 9, e108145.
Gonzalez, J. S., Safren, S. A., Cagliero, E., et al. (2007). Depression, self-care, and medication adherence in type 2 diabetes: relationships across the full range of symptom severity. Diabetes Care, 30, 2222–2227.
Gonzalez, J. S., & Schneider, H. E. (2011). Methodological issues in the assessment of diabetes treatment adherence. Current Diabetes Reports, 11, 472–479.
Gonzalez, J. S., Schneider, H. E., Wexler, D. J., et al. (2013). Validity of medication adherence self-reports in adults with type 2 diabetes. Diabetes Care, 36, 831–837.
Gonzalez, J. S., Shreck, E., Psaros, C., et al. (2015). Distress and type 2 diabetes-treatment adherence: A mediating role for perceived control. Health Psychology, 34, 505–513.
Graham, J. (2009). Missing data analysis: making it work in the real world. Annual Review of Psychology, 60, 549–576S.
Graham, J., Olchowski, A., & Gilreath, T. (2007). How many imputations are really needed? Some practical clarifications of multiple imputation theory. Prevention Science, 8, 206–213.
Graham, J., & Schafer, J. (1999). On the performance of multiple imputation for multivariate data with small sample sizes. In R. Hoyle (Ed.), Statistical strategies for small sample research (pp. 1–29). Thousand Oaks, CA: Sage.
Ho, P. M., Rumsfeld, J. S., Masoudi, F. A., et al. (2006). Effect of medication nonadherence on hospitalization and mortality among patients with diabetes mellitus. Archives of Internal Medicine, 166, 1836–1841.
Houle, J., Beaulieu, M. D., Chiasson, J. L., et al. (2015). Glycaemic control and self-management behaviours in Type 2 diabetes: results from a 1-year longitudinal cohort study. Diabetic Medicine, 32, 1247–1254.
Kennedy, L., & Herman, W. H. (2005). Glycated hemoglobin assessment in clinical practice: comparison of the A1cNow point-of-care device with central laboratory testing (GOAL A1C Study). Diabetes Technology & Therapeutics, 7, 907–912.
Kripalani, S., Risser, J., Gatti, M. E., et al. (2009). Development and evaluation of the Adherence to Refills and Medications Scale (ARMS) among low-literacy patients with chronic disease. Value Health, 12, 118–123.
Lerman, I., Diaz, J. P. M., Ibarguengoitia, M. E. R., et al. (2009). Nonadherence to insulin therapy in low-income, type 2 diabetic patients. Endocrine Practice, 15, 41–46.
Loehlin, J. C. (2012). Latent variable models: An introduction to factor, path, and structural equation analysis. Hove: Psychology Press.
Mayberry, L. S., Gonzalez, J. S., Wallston, K. A., et al. (2013). The ARMS-D out performs the SDSCA, but both are reliable, valid, and predict glycemic control. Diabetes Research and Clinical Practice, 102, 96–104.
Mayberry, L. S., & Osborn, C. Y. (2014). Empirical validation of the information-motivation-behavioral skills model of diabetes medication adherence: A framework for intervention. Diabetes Care, 37, 1246–1253.
Morisky, D. E., Ang, A., Krousel-Wood, M., et al. (2008). Predictive validity of a medication adherence measure in an outpatient setting. The Journal of Clinical Hypertension (Greenwich), 10, 348–354.
Nunnally, J., Bernstein, I. H., & JMF Berge, J. M. F. (1994). Psychometric theory (3rd ed.). New York: McGraw-Hill.
Osborn, C. Y., Cavanaugh, K., Wallston, K. A., et al. (2011a). Health literacy explains racial disparities in diabetes medication adherence. J Health Commun, 16, 268–278.
Osborn, C. Y., Mayberry, L. S., Wagner, J. A., et al. (2014). Stressors may compromise medication adherence among adults with diabetes and low socioeconomic status. Western Journal of Nursing Research, 36, 1091–1110.
Osborn, C. Y., Patel, K. A., Liu, J., et al. (2011b). Diabetes and co-morbid depression among racially diverse, low-income adults. Annals of Behavioral Medicine, 41, 300–309.
Peyrot, M., Barnett, A. H., Meneghini, L. F., et al. (2012a). Factors associated with injection omission/non-adherence in the global attitudes of patients and physicians in insulin therapy study. Diabetes, Obesity & Metabolism, 14, 1081–1087.
Peyrot, M., Barnett, A. H., Meneghini, L. F., et al. (2012b). Insulin adherence behaviours and barriers in the multinational global attitudes of patients and physicians in insulin therapy study. Diabetic Medicine, 29, 682–689.
Peyrot, M., Rubin, R. R., Kruger, D. F., et al. (2010). Correlates of insulin injection omission. Diabetes Care, 33, 240–245.
Piette, J. D., Wagner, T. H., Potter, M. B., et al. (2004). Health insurance status, cost-related medication underuse, and outcomes among diabetes patients in three systems of care. Medical Care, 42, 102–109.
Raghunathan, T., Lepkowski, J., van Hoewyk, J., et al. (2001). A multivariate technique for multiply imputed missing values using a sequence of regression models. Survey Methodology, 27, 85–95.
Ross, S. A., Tildesley, H. D., & Ashkenas, J. (2011). Barriers to effective insulin treatment: the persistence of poor glycemic control in type 2 diabetes. Current Medical Research and Opinion, 27, 13–20.
Rubin, R. R., Peyrot, M., Kruger, D. F., et al. (2009). Barriers to insulin injection therapy: patient and health care provider perspectives. The Diabetes Educator, 35, 1014–1022.
Schectman, J. M., Nadkarni, M. M., & Voss, J. D. (2002). The association between diabetes metabolic control and drug adherence in an indigent population. Diabetes Care, 25, 1015–1021.
Toobert, D., Hampson, S., & Glasgow, R. (2000). The summary of diabetes self-care activities measure: results from 7 studies and a revised scale. Diabetes Care, 23, 943–950.
van Buuren, S., Boxhuizen, H., & Knook, D. (1999). Multiple imputation of missing blood pressure covariates in survival analysis. Statistics in Medicine, 18, 681–694.
VanVoorhis, C. R. W., & Morgan, B. L. (2007). Understanding power and rules of thumb for determining sample sizes. Tutorials in Quantitative Methods for Psychology, 3, 43–50.
Ware, J., Harrington, D., Hunter, D., et al. (2012). Missing data. New Engl J Med, 367, 1353–1354.
Wong, M. C., Wu, C. H., Wang, H. H., et al. (2015). Association between the 8-item Morisky medication adherence scale (MMAS-8) score and glycaemic control among Chinese diabetes patients. The Journal of Clinical Pharmacology, 55(3), 279–287.
Acknowledgments
This research was funded with support from the Vanderbilt Clinical Translational Scientist Award (UL1TR000445) from the National Center for Advancing Translational Sciences. Dr. Osborn is supported by the National Institute of Diabetes and Digestive and Kidney Diseases (K01 DK087894 and R01 DK100694), as is Dr. Gonzalez (R18 DK098742 and R01 DK104845). The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent official views of the National Institutes of Health.
Author contribution
All authors are responsible for the reported research and approve the final submitted version. Author Chandra Y. Osborn is the grantor of this work, and has full access to all data and takes responsibility for data integrity, the accuracy of the data analysis, and the decision to publish the manuscript. Dr. Osborn supervised all aspects of data collection, cleaning, and management, conducted analyses, interpreted findings, co-wrote the introduction, wrote the methods and results, and reviewed and edited the manuscript. Dr. Gonzalez guided the analyses, interpreted findings, wrote the abstract, co-wrote the introduction, wrote the discussion, and reviewed and edited the manuscript. The authors would like to acknowledge Cecilia C. Quintero, Lindsay S. Mayberry, Sahbina Ebba, Karen Calderon, Leo Cortes, Anne Crook, Carmen Mekhail, the Vine Hill Community Clinic personnel, and the patients for their contributions to this research.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
Chandra Y. Osborn and Jeffery S. Gonzalez declare that they have no conflict of interest.
Human and animal rights and Informed consent
All procedures followed were in accordance with ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study.
Rights and permissions
About this article
Cite this article
Osborn, C.Y., Gonzalez, J.S. Measuring insulin adherence among adults with type 2 diabetes. J Behav Med 39, 633–641 (2016). https://doi.org/10.1007/s10865-016-9741-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10865-016-9741-y