International Journal of

Environmental Research
and Public Health

Article
Factors Influencing Medication Non-Adherence
among Chinese Older Adults with Diabetes Mellitus
Ningze Xu 1,2 , Shiyu Xie 1,2 , Yingyao Chen 1,2, *, Jiajia Li 3,4 and Long Sun 3,4
1 School of Public Health, Fudan University, Shanghai 200032, China; nzxu17@fudan.edu.cn (N.X.);
syxie14@fudan.edu.cn (S.X.)
2 Key Lab of Health Technology Assessment, National Health Commission of the People’s Republic of
China (Fudan University), Shanghai 200032, China
3 School of Public Health, Shandong University, Jinan 250012, China; lijiajia@sdu.edu.cn (J.L.);
sunlong@sdu.edu.cn (L.S.)
4 Collaborative Innovation Center of Social Risks Governance in Health, School of Public Health,
Fudan University, Shanghai 200032, China
* Correspondence: yychen@shmu.edu.cn; Tel.: +86-21-3356-5183




Received: 8 May 2020; Accepted: 12 August 2020; Published: 19 August 2020


Abstract: Objectives: This study aimed to examine the prevalence of medication non-adherence
among older adults with diabetes mellitus (DM) in Shandong province, China and to identify its
influencing factors. Methods: A sample of 1002 older adults aged 60 or above with DM was analyzed.
Medication adherence was measured using the Morisky–Green–Levine (MGL) Medication Adherence
Scale. Descriptive statistical analysis, chi-square test, univariate and multivariate logistic regression
analyses were employed. Results: The prevalence of self-reported medication non-adherence among
older adults with DM was 19.9%. Female respondents (adjusted odds ratio (AOR) = 1.56, 95% CI:
1.09–2.24) and respondents who perceived medication adherence to be unimportant (AOR = 1.69, 95%
CI: 1.05–2.74) were more likely to experience medication non-adherence. Respondents with 5 years of
disease duration or longer were less likely (AOR = 0.63, 95% CI: 0.46–0.87) to experience medication
non-adherence. Conclusions: This study showed that about one out of five older adults with DM in
Shandong province, China, experienced medication non-adherence, and that gender, disease duration
and perceived importance of medication adherence were associated with medication non-adherence
in this population group. Provision of counseling and health education programs could be the future
priority to raise patients’ awareness of the importance of medication adherence and improve patients’
self-management of DM.

Keywords: medication non-adherence; diabetes mellitus; elderly; cross-sectional study; China

‘Drugs don’t work in patients who don’t take them’. [1]—C. E. Koop, M.D.

1. Introduction
Characterized by hyperglycemia, diabetes mellitus (DM) is a group of chronic, metabolic diseases
in which the pancreas does not secrete enough insulin, a hormone regulating blood sugar, and/or the
body develops resistance to insulin it produces [2,3]. As the disease progresses, patients are at risks of
experiencing damages to the heart, blood vessels, kidneys, eyes, feet and/or nerves [4]. With population
aging, rapidly increasing urbanization, expanding obesogenic environment and other prevailing risk
factors, the prevalence of DM has been on a steady rise during the past decades, which renders DM a
major public health challenge in the world [4,5]. According to the global estimates released by the
International Diabetes Federation (IDF), there were 463 million adults with DM in 2019, and this figure,
if no countervailing measures are taken, will escalate to 578 million in 2030 and even to 700 million in

Int. J. Environ. Res. Public Health 2020, 17, 6012; doi:10.3390/ijerph17176012 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2020, 17, 6012 2 of 10

2045 with a 51% increase [5]. It is also noteworthy that the prevalence of DM increased with age, and it
is estimated that the global prevalence was 19.9% (111.2 million people) in adults aged 65–79 years
in 2019 [5]. In addition to high prevalence, DM directly caused 1.6 million deaths worldwide and
ranked eighth among the leading causes of death worldwide in 2016 [4,6]. To relieve the heavy burden
of disease directly and indirectly caused by DM, achieving the targets for glycemic control among
patients with DM is crucial [7,8]. Adequate glycemic control is important in preventing or delaying the
onset of complications related with DM, and medication adherence is one of the top determinants to
achieve this goal [4].
According to the commonly used definition, medication adherence refers to ‘the extent to which
patients take medications as prescribed by their healthcare providers’ [9]. Medication non-adherence
is a prevalent phenomenon; even in the settings of clinical trials where patients were rigorously
selected and received close attention to take medications, average medication non-adherence rates
among patients with chronic conditions still range from 22% to 57% [9,10]. Medication non-adherence
also brings significant preventable costs; in the United States, for example, it was estimated that
medication non-adherence costs approximately 100 billion dollars annually [9,10]. Research also found
that medication non-adherence is associated with higher total healthcare costs and hospitalization
costs among patients with type 2 diabetes mellitus (T2DM), suggesting the potential of bringing
significant economic consequences at individual level [11]. In addition, medication non-adherence
is also associated with higher risks for all-cause hospitalization and all-cause mortality in patients
with DM [12]. Non-adherent patients with DM are also at greater risk of developing complications
such as cardiovascular disease, and the diagnosis of complications is significantly related to a lower
quality of life in patients with DM [13,14]. Though non-adherence to prescribed medications affects
all patients regardless of their age-groups, older adults are at higher risk for non-adherence due to
cognitive and functional impairments and prevalence of multiple comorbidities and medications,
while they are more vulnerable to subsequent adverse health outcomes resulting from non-adherence
due to age-related changes in pharmacokinetics and pharmacodynamics [15,16].
Given the significant health and economic consequences caused by medication non-adherence,
especially among older adults with DM, it is imperative to detect non-adherent patients and identify
barriers to medication adherence, so as to prevent and control the prevalence and costs of this
diagnosable and treatable epidemic from further expanding [10]. Among various instruments available
to determine behaviors of interest and measure medication non-adherence, the Morisky–Green–Levine
(MGL) Medication Adherence Scale is one of the representative tools commonly used to diagnose
medication non-adherence across various settings [10]. With regard to barriers to medication adherence,
the World Health Organization (WHO) acknowledged that adherence to long-term therapies is a
multidimensional phenomenon interactively influenced by five dimensions of factors, which are
‘social and economic factors, healthcare team and system-related factors, condition-related factors,
therapy-related factors, and patient-related factors’ [16]. As the world population is aging faster
than ever before with a rapidly increasing number of patients with DM, how to improve medication
non-adherence in older adults with DM emerges as a potential challenge to the health systems of many
countries, especially those with restrained resources, due to the call for systematic and multifaceted
interventions [16–18].
With both the largest population with DM and the largest older population aged 60 years or
above in the world, China, compared with many other countries, is at a higher risk of bearing
heavy disease and economic burdens resulting from medication non-adherence in older patients with
DM [17,18]. Though medication non-adherence in this vulnerable population group has received some
attention in recent years, previous studies were mainly conducted at a single or a few hospitals or
community health centers, which could not fully represent general older adults with DM due to the
potential sampling bias and did not reflect the dichotomous rural-urban structure in China [19–21].
Furthermore, many only explored certain dimensions of factors associated with medication adherence
without using a theoretically grounded conceptual framework and/or a commonly accepted medication
Int. J. Environ. Res. Public Health 2020, 17, 6012 3 of 10

adherence scale [19–21]. To our knowledge, little is known about how various dimensions of factors
are simultaneously associated with medication non-adherence in older adults with DM in China.
Filling this gap in the literature, this study aims to examine the extent of self-reported medication
non-adherence in older adults with DM and to identify factors associated with this phenomenon.

2. Materials and Methods

2.1. Study Design and Data Collection

This study was based on the Shandong Province Elderly Family Health Service Survey conducted
in 2017. Detailed sampling design has been described in previous publications [22]. In general,
stratified multi-stage random sampling design was employed to interview older adults aged 60 or
above, and the survey was administered in person. Caregivers did not complete the survey on behalf
of respondents. In the first stage, a total of 6 county-level areas were selected as the primary sampling
units (PSUs) out of 137 county-level areas in Shandong province, among which 1 urban district and
1 rural county were selected in each of eastern, central, and western regions of Shandong Province
to reflect the regional socioeconomic disparities and the dichotomous rural-urban structure. In the
second stage, 18 rural villages and 18 urban/suburban communities were selected from each PSU as
the secondary sampling units (SSUs). In the third stage, an average number of 66 older adults were
randomly selected per SSU based on rosters of local residents.
Among 7088 older adults who were selected and interviewed, 18 failed to complete the survey,
resulting in a total sample of 7070 respondents. This study targeted a sample of 1002 older adults with
DM. Respondents were identified as patients with DM if they were previously confirmed by physicians
and were taking anti-diabetic medication/had taken anti-diabetic medication before. Respondents
were perceived as having DM-related complication(s) if they received previous confirmation from
physicians. Data with less than 10% of missing values were imputed with medians for continuous
variables and modes for categorical or dichotomous variables. Before administering face-to-face
interviews, informed consent for data collection and analysis was obtained from eligible participants
who were willing and able to understand and answer interviewers’ questions.

2.2. Dependent Variable

We used the MGL Medication Adherence Scale that was proved to have good concurrent and
predictive validity and good internal consistency [23]. Each of the four questions in the scale is asked
in the reverse direction, the purpose of which is to reduce the potential bias of social desirability,
namely, patients’ behaviors to please the interviewers to demonstrate that they are always taking their
medications as instructed [23]. In the MGL Medication Adherence Scale, 0 point is assigned to the
“yes” response, and 1 point is assigned to the “no” response [23]. Thus, the higher the score, the higher
the adherence of the patients. The MGL Medication Adherence Scale assesses both unintentional
medication non-adherence (forgetfulness or carelessness) and intentional medication non-adherence
(stop taking prescribed medicine(s) when feeling better or worse) [23]. The full MGL score ranges
from 0–4, with 0–1 being classified as having low adherence, 2–3 being classified as having moderate
adherence, and 4 being classified as having high adherence [23]. Since the purpose of this study is to
identify factors associated with medication non-adherence among older adults with DM, the full score
was dichotomized into two groups: the adherent group (MGL score: 2–4) and the non-adherent group
(MGL score: 0–1).

2.3. Independent Variables

Independent variables were chosen from the survey questionnaire according to the five dimensions
of adherence conceptual framework [16]. Social and economic factors included gender (male, female),
residence (urban, township, rural), age group (60–69, 70–79, ≥80), education level (junior or above,
below junior), marital status (married, single), employment status (employed, unemployed), and
Int. J. Environ. Res. Public Health 2020, 17, 6012 4 of 10

personal annual income (USD >8882.7, USD 0–8882.7; USD 1 = CNY 6.7547 on average in 2017).
Healthcare team and system-related factors included type of health insurance (Urban Employee
Basic Medical Insurance (UEBMI), Urban and Rural Residents Basic Medical Insurance (URRBMI),
others/none). Condition-related factors included disease duration (<5 years, ≥5 years) and incidence of
complication (no, yes). Therapy-related factors included type of medication (oral hypoglycemic agent
(OHA), insulin, both). Patient-related factors included perceived importance of medication adherence
(important, unimportant) and self-rated mental health status in the past month (good, normal, poor).

2.4. Statistical Analysis

All analyses were conducted using Stata 16.1 (Stata Corp., College Station, TX, USA). Frequencies
and percentages were calculated to describe categorical or dichotomous variables. We used chi-square
test to determine the bivariate association between respondents’ characteristics and medication
non-adherence. Unadjusted and adjusted logistic regression analyses were conducted to identify
factors influencing medication non-adherence among older adults with DM. Independent variables
with a p-value of less than 0.2 in the unadjusted analyses were selected as candidate independent
variables for the adjusted model. We employed backward elimination on candidate independent
variables with a p-value cutoff of 0.05 to identify independent variables significantly associated
with medication non-adherence. Strength of associations between respondents’ characteristics and
medication non-adherence was described using crude odds ratios (CORs) and adjusted odds ratios
(AORs) with the corresponding 95% confidence intervals (CIs).

2.5. Ethical Considerations

The Research Ethics Committee of Shandong University granted the ethical approval for this
survey (No. 20170110). Participation in the interview was voluntary with informed consent, and
respondents’ data were collected anonymously.

3. Results

3.1. Respondents’ Characteristics by the Level of Medication Adherence

Table 1 shows respondents’ characteristics by the level of medication adherence. Of a total of
1002 older adults with DM, the majority of respondents were female (69.6%), aged under 80 years
old (95.9%), received an education below junior level (71.5%), married (82.9%), unemployed (77.5%)
and earned a personal annual income of USD 8882.7 or below (96.8%). As for other dimensions of
characteristics, 70.6% (n = 707) had URRBMS, 67.4% (n = 675) had a disease duration of 5 years or
above, 84.1% (n = 843) did not experience the incidence of complication, 84.4% only took OHA (n = 846),
90.6% (n = 908) perceived medication adherence to be important, and 75.4% (n = 756) had good mental
health status. The overall prevalence of medication non-adherence was 19.9%, and the gender-specific
prevalence was 15.4% in males and 21.8% in females.

3.2. Respondents’ Self-Reported Medication Non-Adherence by the MGL Medication Adherence Scale
Table 2 presents the details of respondents’ self-reported medication non-adherence by the MGL
Medication Adherence Scale. Among 1002 respondents, 421 (42.0%) sometimes forgot to take prescribed
medicine, 299 (29.8%) were careless occasionally about taking medicine; 254 (25.4%) sometimes stopped
taking medicine when feeling better; and 170 (17.0%) stopped taking medicine if they felt worse when
taking the medicine sometimes. Out of 1002 respondents, 46.2% (n = 463) were highly adherent,
33.9% (n = 340) had moderate adherence, and 19.9% (n = 199) had low adherence. In addition, the
percentage of respondents reporting unintentional non-adherence was 44.5% (n = 446), the percentage
of respondents reporting intentional non-adherence was 33.2% (n = 333), and the percentage of
respondents reporting both unintentional and intentional non-adherence was 24.0% (n = 240).
Int. J. Environ. Res. Public Health 2020, 17, 6012 5 of 10

Table 1. Summary of respondents’ characteristics by level of medication adherence.

Characteristics Total Adherent Non-Adherent χ2 p-Value

N 1002 803 (80.1) 199 (19.9)
Social and economic factors
Gender 5.456 0.019
Male 305 (30.4) 258 (84.6) 47 (15.4)
Female 697 (69.6) 545 (78.2) 152 (21.8)
Residence 4.527 0.104
Urban 326 (32.5) 273 (59.4) 53 (64.0)
Township 72 (7.2) 54 (6.7) 18 (9.1)
Rural 604 (60.3) 476 (33.9) 128 (26.9)
Age group 5.224 0.073
60–69 528 (52.7) 409 (77.5) 119 (22.5)
70–79 433 (43.2) 361 (83.4) 72 (16.6)
≥80 41 (4.1) 33 (80.5) 8 (19.5)
Education level a 2.953 0.086
Junior or above 286 (28.5) 239 (83.6) 47 (16.4)
Below junior 716 (71.5) 564 (78.8) 152 (21.2)
Marital status 2.863 0.091
Married 831 (82.9) 674 (81.1) 157 (18.9)
Single b 171 (17.1) 129 (75.4) 42 (24.6)
Employment status 1.927 0.165
Employed 225 (22.5) 173 (76.9) 52 (23.1)
Unemployed c 777 (77.5) 630 (81.1) 147 (18.9)
Personal Annual Income 3.850 0.050
USD >8882.7 32 (3.2) 30 (93.8) 2 (6.2)
USD 0–8882.7 970 (96.8) 773 (80.0) 197 (20.0)
Health care team and system-related factors
Health insurance d 3.469 0.176
UEBMS 262 (26.1) 220 (84.0) 42 (16.0)
URRBMS 707 (70.6) 556 (78.6) 151 (21.4)
Others/None 33 (3.3) 27 (81.8) 6 (18.2)
Condition-related factors
Disease duration 7.354 0.007
<5 years 327 (32.6) 246 (75.2) 81 (24.8)
≥5 years 675 (67.4) 557 (82.5) 118 (17.5)
Complication 0.312 0.576
No 843 (84.1) 673 (79.8) 170 (20.2)
Yes 159 (15.9) 130 (81.8) 29 (18.2)
Therapy-related factors
Type of medication 3.323 0.190
OHA e 846 (84.4) 670 (79.2) 176 (86.6)
Insulin 70 (7.0) 61 (8.1) 9 (5.2)
Both 86 (8.6) 72 (9.6) 14 (8.1)
Patient-related factors
Perceived importance of medication
5.120 0.024
adherence
Important 908 (90.6) 736 (81.1) 172 (18.9)
Unimportant 94 (9.4) 67 (71.3) 27 (28.7)
Self-rated mental health status 4.080 0.130
Good 756 (75.4) 616 (81.5) 140 (18.5)
Normal 183 (18.3) 137 (74.9) 46 (25.1)
Poor 63 (6.3) 50 (79.4) 13 (20.6)
a Junior or above: middle school/high school/technical school/technical secondary school/junior college/undergraduate
or above; below junior: illiterate/elementary school; b single: single/divorced/widowed/others; c unemployed:
retired/unemployed; d Urban Employee Basic Medical Insurance (UEBMI) and Urban and Rural Residents Basic Medical
Insurance (URRBMI) are government-run health insurance programs launched for different population groups with an
aim of achieving universal coverage of the Chinese population and health services; e oral hypoglycemic agent (OHA).
Int. J. Environ. Res. Public Health 2020, 17, 6012 6 of 10

Table 2. Details of respondents’ self-reported medication non-adherence status.

Item of the MGL Medication Adherence

Frequency (Yes) Percentage (%)
Scale a
Do you ever forget to take your medicine? 421 42.0
Are you careless at times about taking
299 29.8
your medicine?
When you feel better, do you sometimes
254 25.4
stop taking your medicine?
Sometimes if you feel worse when you
170 17.0
take the medicine, do you stop taking it?
Level of Medication Adherence Frequency Proportion (%)
High adherence 463 46.2
Moderate adherence 340 33.9
Low adherence 199 19.9
Intentional versus Unintentional
Frequency Percentage (%)
Non-adherence
Unintentional non-adherence 446 44.5
Intentional non-adherence 333 33.2
Both 240 24.0
Total 1002 100.0
a the Morisky–Green–Levine (MGL) Medication Adherence Scale.

3.3. Factors Influencing Medication Non-Adherence among Older Adults with DM

The unadjusted and adjusted associations between respondents’ characteristics and medication
non-adherence are presented in Table 3. In the unadjusted model, female respondents (COR = 1.53,
95% CI: 1.07–2.19), those who perceived medication adherence to be unimportant (COR = 1.72, 95%
CI: 1.07–2.78) and self-reported normal mental status (COR = 1.48, 95% CI: 1.01–2.16) were more
likely to self-report medication non-adherence. Respondents aged 70–79 years old (COR = 0.69,
95% CI: 0.50–0.95) and those with longer disease duration (COR = 0.64, 95% CI: 0.47–0.89) were
less likely to self-report medication non-adherence. In the adjusted model, several factors were
still independently associated with medication non-adherence after controlling for other factors.
In particular, female participants were more likely than male participants to experience medication
non-adherence (AOR = 1.56, 95% CI: 1.09–2.24). Respondents who have disease durations of 5 years or
longer were less likely to experience medication non-adherence than respondents with shorter disease
duration (AOR = 0.63, 95% CI: 0.46–0.87). Respondents who perceived medication adherence to be
unimportant were more likely to experience medication non-adherence than those who perceived
medication non-adherence as important (AOR = 1.69, 95% CI: 1.05–2.74).

Table 3. Factors influencing medication non-adherence among older adults with DM.

Characteristics Unadjusted Model Adjusted Model a

Level
(Reference Group) COR b (95% CI) p-Value AOR c (95% CI) p-Value
Gender (Male) Female 1.53 (1.07–2.19) 0.020 1.56 (1.09–2.24) 0.016
Residence (Urban) Township 1.72 (0.93–3.16) 0.082
Rural 1.39 (0.97–1.97) 0.070
Age group (60–69) 70–79 0.69 (0.50–0.95) 0.023
≥80 0.83 (0.37–1.85) 0.654
Education level
Below junior 0.90 (0.79–1.03) 0.113
(Junior or above)
Marital status (Married) Single 1.40 (0.95–2.06) 0.092
Employment status
Unemployed 0.78 (0.54–1.11) 0.166
(Employed)
Int. J. Environ. Res. Public Health 2020, 17, 6012 7 of 10

Table 3. Cont.

Characteristics Unadjusted Model Adjusted Model a

Level
(Reference Group) COR b (95% CI) p-Value AOR c (95% CI) p-Value
Personal annual income
USD 0–8882.7 3.82 (0.91–16.13) 0.068
(USD >8882.7)
Insurance (UEBMI) URRBMI 1.42 (0.98–2.07) 0.066
Others/None 1.16 (0.45–2.99) 0.753
Disease duration
≥5 years 0.64 (0.47–0.89) 0.007 0.63 (0.46–0.87) 0.005
(<5 years)
Complication (No) Yes 0.88 (0.57–1.37) 0.577
Type of medication (OHA) Insulin 0.56 (0.27–1.15) 0.116
Both 0.74 (0.41–1.34) 0.323
Perceived importance of
Unimportant 1.72 (1.07–2.78) 0.025 1.69 (1.05–2.74) 0.032
adherence (Important)
Mental health status (Good) Normal 1.48 (1.01–2.16) 0.045
Poor 1.14 (0.60–2.16) 0.679
aIndependent variables were considered for the adjusted model if they had a p-value of 0.2 or less in the unadjusted
model; b crude odds ratio (COR); c adjusted odds ratios (AOR).

4. Discussion
Medication non-adherence is a serious challenge to the self-management of DM among adults with
DM, especially among older adults, and its downstream effects will be multiplied if left unaddressed and
will be manifested as increased incidence and prevalence of major complication and heavier disease and
economic burdens of the disease. Therefore, the objectives of this study were to examine the prevalence
of medication non-adherence among older adults with DM and to identify its influencing factors.
The prevalence of self-reported medication non-adherence among older adults with DM in
Shandong province was 19.9% in this study, which was close to the finding reported from Cambodia
(17.2%) [24] but lower than the finding reported from Algeria (31.3%) [25]. Disparities between findings
could be explained by differences in the sampling design, study settings, health systems, respondents’
socioeconomic characteristics, and/or instruments used to measure medication adherence.
In this current study, females were more likely to be non-adherent to their prescribed medications
than males, which is consistent with some previous studies [26,27]. Considering that there is mixed
evidence for the association between medication non-adherence and gender [25,28], future research
is needed to explore the mechanisms behind gender effects. We found that disease duration was an
independent factor influencing medication non-adherence. The longer the disease duration, the smaller
the likelihood of older adults with DM being non-adherent to their prescribed medications. A possible
explanation for this association is that patients gain increasing knowledge and awareness of DM as the
disease progresses, which lays the foundation for a better adherence to prescribed medications [29].
Our study also demonstrated that respondents who perceived medication adherence as
unimportant were more likely to experience medication non-adherence. This finding could be
potentially attributed to the property of the MGL Medication Adherence Scale that it measures both
intentional non-adherence (forgetfulness or carelessness) and un-intentional medication non-adherence
(stop taking prescribed medication(s) when feeling better or worse) [23]. In our study, the respondents
in the non-adherent group had an MGL score of 0–1, which implies that non-adherent respondents,
regardless of which specific scale items to which they answered “yes”, experienced both intentional
and un-intentional medication adherence. Therefore, it is intuitive that perceived importance of
medication adherence was statistically significantly associated with medication non-adherence among
older adults with DM. Fortunately, this factor is modifiable through providing counseling and health
education programs, which demonstrated promising effects in many settings [30,31]. To overcome this
barrier to adherence, health professionals will play a central role in changing patients’ perception of
the importance of medication adherence and improving self-management of DM.
This study has several strengths and limitations. The stratified multistage random sampling design
of this study ensured that enrolled respondents represented different socioeconomic backgrounds.
Int. J. Environ. Res. Public Health 2020, 17, 6012 8 of 10

Additionally, the sample size of this study was larger compared with many previous studies
and therefore is of better potential to identify factors associated with medication non-adherence.
Furthermore, this study targeted older adults with DM, a population group that is vulnerable to the
negative consequences of medication non-adherence, and provided evidence on the characteristics of
older patients who were at higher risks of experiencing medication non-adherence.
Several limitations of the present study should also be noted while interpreting the findings. First,
this study was based on patients’ self-reported medication adherence and therefore was inevitably
subject to recall bias and self-report bias. Second, the study did not distinguish between patients
with type 1 diabetes mellitus (T1DM) and patients with type 2 diabetes mellitus (T2DM), nor did it
distinguish between different types of DM complications. Third, the cross-sectional design of this study
only allows for the establishment of association between respondents’ characteristics and medication
adherence. Finally, this study only considered factors available in the survey questionnaire, and we
acknowledge that there are some other confounding factors associated with medication non-adherence
in addition to the factors included in this study. To better understand factors influencing medication
non-adherence among older adults with DM and explore underlying mechanisms, future study need
to pay more attention to the collection of DM-specific data, such as types of complications and types
and doses of anti-diabetic medications.

5. Conclusions
In conclusion, this study showed that about one out of five older adults with DM in Shandong
province, China, experienced medication non-adherence, and that gender, disease duration and
perceived importance of medication adherence were associated with medication non-adherence in
this population group. Medication non-adherence among Chinese older adults with DM is a public
health problem that demands attention and efforts from decision-makers and professionals in the
healthcare sector. To counter this pressing challenge, future priorities could be to provide counseling
and health education programs to raise patients’ awareness of the importance of medication adherence
and improve patients’ self-management of DM.

Author Contributions: N.X. participated in data collection, analyzed the data and drafted the manuscript. S.X.
and Y.C. contributed to the interpretation of the results and revised the manuscript. Y.C. also conceived the
idea. J.L. and L.S. participated in data collection, reviewed the manuscript and provided valuable comments.
All authors have read and agreed to the published version of the manuscript.
Funding: This study was funded by China Medical Board Health Technology Assessment Collaborating Program
(Grant No. 16-251) and the National Natural Science Foundation of China (Grant Nos. 71673169 and 71673170).
Acknowledgments: The authors are grateful to all survey participants for their contribution and collaboration.
The authors wish to express their sincere gratitude to reviewers, editors and especially Donald E. Morisky for
their insightful comments and suggestions and dedicated contribution to the publication of this article.
Conflicts of Interest: The authors declare no conflict of interest.

Abbreviations
DM Diabetes Mellitus
T2DM Type 2 Diabetes Mellitus
MGL Morisky–Green–Levine Medication Adherence Scale
UEBMI Urban Employee Basic Medical Insurance
URRBMI Urban and Rural Residents Basic Medical Insurance
OHA Oral Hypoglycemic Agent
COR Crude Odds Ratio
AOR Adjusted Odds Ratio
Int. J. Environ. Res. Public Health 2020, 17, 6012 9 of 10

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