Jurnal Ilmu Farmasi dan Farmasi Klinik
(Journal of Pharmaceutical Science and Clinical Pharmacy)
ISSN 1693-7899 (print) - 2716-3814 (online)
DOI: 10.31942/jiffk.v21i1.9529

Evaluation of Oral Antidiabetic Medication Adherence
Among Diabetes Mellitus Patients in the Outpatient
Department of RSUD Prembun in 2022
Aiyen Dasa Novita1, Tri Cahyani Widiastuti2*, Endang Yuniarti3, Husnul Khuluq4
1 Pharmacy Study Program, Faculty of Health Sciences, Muhammadiyah University of Gombong, Kebumen,

Central Java, Indonesian
2 Pharmacist Study Program, Faculty of Health Sciences, Muhammadiyah University of Gombong, Kebumen,

Central Java, Indonesian
3 Program Studi Farmasi, Fakultas Ilmu Kesehatan, Universitas Muhammadiyah Gombong, Kebumen, Jawa

Tengah, Indonesian
4 Pharmacist Study Program, Faculty of Health Sciences, Muhammadiyah University of Gombong, Kebumen,

Central Java, Indonesian

ABSTRACT: Diabetes mellitus is a chronic condition characterized by elevated blood glucose
levels. At Prembun Regional General Hospital (RSUD Prembun), diabetes mellitus ranks first
among the top ten most prevalent diseases. Medication adherence in patients with diabetes
mellitus is crucial to prevent the onset of complications. This study aims to determine the level
of adherence to oral antidiabetic medication and to examine the association between patient
characteristics and medication adherence among diabetes mellitus patients in 2022 at RSUD
Prembun. A cross-sectional study design was employed using purposive sampling, involving
85 respondents. The Medication Adherence Report Scale (MARS-10) questionnaire was used
as the research instrument to assess medication adherence. Data were analyzed using the Chisquare test via SPSS software. The results showed that out of 85 respondents, 80 demonstrated
high adherence, while 5 had low adherence. Significant associations were found between
medication adherence and patient characteristics, including gender (p = 0.048), the number of
medications taken (p = 0.004), comorbidities (p = 0.030), and duration of illness (p = 0.026). In
conclusion, there is a statistically significant relationship between medication adherence and
patient characteristics, with p-values < 0.05.
Keywords: Diabetes; Adherence; Antidiabetic

*Corresponding author:

Name
: Tri Cahyani Widiastuti
Email
: tricahyani@unimugo.ac.id
Address : Pharmacist Study Program, Faculty of Health Sciences, Muhammadiyah University of Gombong,
Kebumen, Central Java, Indonesian

127
Submitted: 08-11-2024; Received in Revised Form: 10-02-2025; Accepted: 18-06-2025

Novita et al.

INTRODUCTION
Diabetes mellitus is a chronic condition characterized by elevated blood glucose
levels, or hyperglycemia, which is a hallmark feature of the disease (International Diabetes
Federation, 2017). In 2019, the global prevalence of diabetes mellitus was 9.3%, affecting
an estimated 463 million individuals aged 20–79 years. The Southeast Asia region, which
includes Indonesia, ranked third in terms of regional prevalence, with a rate of 11.3%.
Among the ten countries with the highest number of diabetes mellitus cases in 2019,
Indonesia ranked seventh, with a prevalence affecting approximately 10.7 million
individuals. This places Indonesia among the top ten countries with the highest diabetes
burden in the Southeast Asian region (International Diabetes Federation, 2017). According
to the 2018 Basic Health Research (Riskesdas) report, the prevalence of diabetes mellitus
based on physician diagnoses across all age groups in Central Java Province reached 1.6%,
amounting to approximately 132,565 individuals. In Kebumen Regency, the prevalence of
diabetes mellitus based on physician diagnoses in the same year was reported at 3,162
individuals, placing it fifth among all regencies in Central Java in terms of diabetes
prevalence. (Riskesdas, 2018).
The primary goal of diabetes mellitus therapy is to improve patients' quality of life
and to prevent the onset of complications. Complication prevention is achieved by
maintaining stable blood glucose levels through lifelong, routine treatment, as diabetes
mellitus is not a curable condition. Uncontrolled diabetes can lead to various organ
complications, including damage to the kidneys, eyes, and nerves, as well as an increased
risk of cardiovascular diseases and heart-related conditions (Warsini, 2020). Therapeutic
approaches for patients with diabetes mellitus include both non-pharmacological and
pharmacological interventions. Non-pharmacological therapy involves health education,
which should be provided broadly to the general public, as well as specifically to both newly
diagnosed and long-term diabetes patients. It also includes dietary modifications for
overweight or obese individuals, and regular physical activity—such as 30-minute exercise
sessions performed 3–4 times per week. Pharmacological therapy is initiated when nonpharmacological measures are insufficient or ineffective in maintaining glycemic control.
Pharmacological interventions consist of oral antihyperglycemic agents and insulin
therapy.
Adherence is a key determinant in achieving the effectiveness of any health
intervention. It is often defined as the extent to which a patient is willing and able to follow
prescribed health-related behaviors. However, adherence is frequently misunderstood as
a passive act, with many healthcare providers assuming that patients will automatically
comply with medical instructions. In reality, adherence is an active and intentional process
in which patients make their own decisions about whether or not to follow treatment
recommendations, including medication intake, independent of direct supervision or
prompting from healthcare providers (Warni Emerensiana, 2022). Several factors
influence medication adherence, including educational level, age, gender, occupation,
duration of illness, number of medications prescribed, presence of comorbidities, income
level, adverse effects of medication, patient–physician communication, health literacy, and
forgetfulness. According to a study by Nurtalenta Lafau (2021), the majority of diabetes
mellitus patients were aged between 40 and 45 years (46.7%). Age was found to be closely
associated with increased blood glucose levels among diabetes mellitus patients. As
individuals grow older, the risk of developing diabetes mellitus tends to rise, with the aging
process itself contributing as a potential factor in the onset of the disease. However, a study
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conducted by Novalisa (2021) reported no significant association between medication
adherence and clinical outcomes. This finding indicates that even though patients with type
2 diabetes mellitus were categorized as adherent to medication, their adherence did not
necessarily correlate with improved clinical outcomes.
RSUD Prembun is a healthcare facility that provides treatment services for diabetes
mellitus. In 2018, diabetes mellitus ranked fourth among the top ten most common
diseases at RSUD Prembun. In 2019, it rose to third place, and by 2020, it had become the
most prevalent condition reported at the hospital (Renstra, 2021). According to a
preliminary study, the number of outpatient diabetes mellitus cases at RSUD Prembun was
recorded at 331 patients in 2021, increasing to 468 patients in 2022.
Based on this increasing trend, it is necessary to conduct a study evaluating
adherence to oral antidiabetic medications among diabetes mellitus patients at RSUD
Prembun. This study aims to assess the level of adherence to oral antidiabetic drugs and to
examine the association between patient characteristics and medication adherence among
diabetes mellitus outpatients in 2022 at RSUD Prembun.
METHODS
The design of this study is a prospective, non-experimental, observational study.
Although descriptive analysis is used to summarize the data, it is not sufficient to test the
relationship between patient characteristics and medication adherence. Therefore, this
study employs an analytical approach with a cross-sectional design to examine the
association between independent and dependent variables.
The independent variables include gender, age, education, occupation, number of
medications, comorbidities, duration of illness, and income. The dependent variable is the
level of adherence to oral diabetes mellitus medication. The study was conducted in March
2023 at RSUD Prembun.
Population and Sample
The population in this study consists of adult diabetes mellitus patients using oral
antidiabetic medications and receiving treatment at RSUD Prembun in 2023. The sample
used in this study comprises diabetes mellitus patients at RSUD Prembun who meet the
inclusion criteria as follow:
1. Diabetes mellitus patients with or without comorbidities.
2. Diabetes mellitus patients who are willing to participate as respondents and complete
the questionnaire from the beginning to the end.
3. Patients who have been undergoing treatment for a minimum duration of 1 month,
using oral antidiabetic medications.
4. Diabetes mellitus patients aged ≥ 18 years.
5. Diabetes mellitus patients who are prescribed oral antidiabetic medications.
Exclusion criteria are not the opposite of inclusion criteria, but rather conditions
where participants meet the inclusion criteria but must still be excluded from the study due
to specific reasons. In this study, the exclusion criteria are as follows:
1. Diabetes mellitus patients who do not complete the questionnaire from beginning to
end.
2. Patients who have been newly diagnosed with diabetes mellitus.
3. Patients who are unwilling to participate in the study.
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Research Instrument
This study uses the Medication Adherence Report Scale-10 (MARS-10)
questionnaire, which contains 10 questions developed by Thompson, J. Kulkarni, and A. A.
Sergejew to assess the adherence of patients to oral antidiabetic medications. The
questionnaire is used to collect data on medication adherence in diabetes mellitus patients
(Thompson et al., 2000).
Data Analysis
The data collected from respondents were analyzed using the Chi-Square (χ²) test
with a confidence level of 95% (α = 0.05). A p-value of less than 0.05 was considered
statistically significant, indicating a meaningful association between the independent
variables (such as gender, age, education, occupation, number of medications,
comorbidities, duration of illness, income) and the dependent variable, which is the level of
adherence to oral antidiabetic medication.
Patient adherence levels were categorized based on the Medication Adherence Report
Scale-10 (MARS-10), a validated instrument developed by Thompson et al. (2000). The
total score ranges from 0 to 40. In this study, the adherence scores were classified into two
categories:
1. High adherence: scores between 21–40
2. Low adherence: scores between 0–20
These categories were used to further examine the distribution and characteristics
of respondents with different adherence levels. All results were presented in tabular form
to describe the relationship between patient characteristics and adherence to oral diabetes
medication at RSUD Prembun during the study period in March 2023.
RESULT AND DISCUSSION
Respondent Characteristics
Based on the research findings, most patients suffering from diabetes mellitus who used
oral antidiabetic medications at RSUD Prembun in the age range of 46-60 years were 47
people (55.3%). This result is in line with the study conducted by Mulyani (Mulyani, 2022)
which reported that 37 people (41.1%) in the same age range suffered from diabetes
mellitus. According to Perkeni (2021), individuals over the age of 40 have a high risk of
developing diabetes mellitus. This is due to the increase in glucose levels as people age,
which consequently raises the risk of developing diabetes mellitus. As people age, the
body's physiological functions tend to decline, contributing to an increased risk of
developing diabetes mellitus (PERKENI, 2021). This is because as people age, glucose levels
tend to increase, which in turn raises the risk of developing diabetes mellitus. As age
increases, the risk of experiencing diabetes mellitus rises due to the decline in physiological
functions (Brunner dan Suddarth, 2016a). The data on age and gender characteristics can
be seen in Tables 1 and 2.

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Table 1. Age Characteristics
Age Group
18 – 25 years
26 – 35 years
36 – 45 years
46 – 60 years
>61 years
Total

Number (N)
0
0
14
47
24
85

Percentage (%)
0
0
16.5
55.3
28.2
100

Table 2. Gender characteristic
Gender
Female
Male
Total

Number (N)
49
36
85

Percentage (%)
57.6
42.4
100

Based on the gender characteristics, most diabetes mellitus patients at RSUD
Prembun were female, with 49 respondents (57.6%), while the remaining patients were
male, totaling 36 respondents (42.4%). The results of this study are consistent with those
of a study conducted by Mulyani (2022), which found that 53 female respondents (58.9%)
and 37 male respondents (41.1%) participated. Gender is considered one of the nonmodifiable risk factors for diabetes mellitus (Infodatin, 2020).
According to the 2018 Riskesdas, the prevalence of diabetes mellitus is higher in
females compared to males. According to Punthakee, females are at a greater risk of
developing diabetes mellitus than males (Punthakee et al., 2018). This is because females
tend to have a higher body mass index (BMI) compared to males, which is a risk factor for
obesity. Additionally, females are more susceptible to fat accumulation within the body due
to hormonal processes, as they undergo menstruation and menopause (Soeharto, 2004.
Women are also more prone to experiencing stress, which can trigger an increase in the
hormone epinephrine. This hormone stimulates the mobilization of glucose, fatty acids, and
lactate. As an insulin-antagonist hormone, epinephrine can inhibit insulin action and
subsequently affect blood glucose levels (Brunner & Suddarth, 2016b). The data on
educational characteristics can be seen in Table 3.
Table 3. Educational Characteristics
Education Level
No School
Elementary School (SD)
Junior High School (SMP)
Education Level
No School
Elementary School (SD)

Number (N)
0
49
14
Number (N)
0
49

Percentage (%)
0
57.6
16.5
Percentage (%)
0
57.6

Based on Educational Characteristics, it shows that most diabetes mellitus patients
at RSUD Prembun have completed elementary school, with 49 respondents (57.6%),
followed by those with high school/vocational education (SMA/SMK) with 19 respondents
(22.4%), junior high school education (SMP) with 14 respondents (16.5%), and the
remaining patients have higher education, totaling 3 respondents (3.5%). According to the
2011 Introduction to Public Health book, in wealthy countries, an additional year of
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Novita et al.

education can reduce mortality rates by approximately 8%, or twice as much, either
directly or indirectly.
The Educational Characteristics can influence an individual's learning process. The
higher the level of education a person achieves, the more information they can acquire,
resulting in greater knowledge. It is expected that higher education will encourage
individuals to adopt healthier behaviors and help prevent diseases, including diabetes
mellitus, as well as improve dietary habits.
Behavioral changes in individuals can be influenced by knowledge, attitudes, and
environmental factors (Notoatmodjo, 2011). Education can also enhance an individual's
knowledge and awareness, motivating them to make changes or take actions for health
maintenance and improvement, including in the area of treatment (Aditya et al., 2022).
Based on occupation in table 4, the majority of diabetes mellitus patients at RSUD
Prembun are housewives (IRT), with 30 respondents (35.3%), followed by farmers with 22
respondents (25.9%), those not working with 10 respondents (11.8%), laborers and civil
servants (PNS) with 8 respondents (9.4%) each, entrepreneurs with 5 respondents (5.9%),
and others, such as traders and tailors, with 2 respondents (2.3%). One of the contributing
factors to the development of diabetes mellitus in an individual is the lack of physical
activity (Decroli, 2019). However, in this study, the most common group suffering from
diabetes mellitus at RSUD Prembun was housewives (IRT). According to research by
Mokolomban (2018), housewives are considered to have a job with relatively light physical
activity. The data on occupational characteristics and the distribution of patients based on
the number of medications used can be seen in Tables 4 and 5.
Table 4. Occupational Characteristics
Occupation
Farmer
Entrepreneur (Wiraswasta)
Housewife (IRT)
Civil Servant (PNS)
Laborer (Buruh)
Not Working
Others
Total

Number (N)
22
5
30
8
8
10
2
85

Percentage (%)
25.9
5.9
35.3
9.4
9.4
11.8
2.3
100

Table 5. Distribution of Patients Based on the Number of Medications Used
Number of Medications
1 medication
2 medications
>3 medications
Total

Number (N)
29
28
28
85

Percentage (%)
34.2
32.9
32.9
100

Based on the number of medications consumed in table 5, most diabetes mellitus
patients at RSUD Prembun used a single medication, totaling 29 respondents (34.2%).
Meanwhile, 28 respondents (32.9%) used two or three medications. These findings
indicate that many respondents used only one medication. This is consistent with the study
conducted by Aditya, which reported that in Rampal Malang Auxiliary Hospital, the highest
proportion of patients used a single drug regimen, with a percentage of 23.33% (Aditya et
al., 2022b). Patients who receive monotherapy are generally more adherent to their
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medication regimen compared to those undergoing combination therapy. Medication
adherence is influenced by the number of drugs prescribed, with patients taking fewer
medications typically showing higher adherence levels (Prautami & Ramatillah, 2020).
Patients who are prescribed a greater number of medications tend to exhibit poorer
medication adherence (Rohi, 2020).
The results, as shown in Tables 4 and 5, indicate variations in medication adherence
based on occupational background and the number of medications used. of this study
indicate that most patients receiving monotherapy demonstrated better adherence
compared to those receiving combination antidiabetic therapy. Combination therapy may
involve two or three types of antidiabetic medications, which can lead to decreased
adherence due to the increased complexity of the medication regimen (Yach, 2003). The
data on the distribution of patients based on the presence of comorbidities can be seen in
Table 6.
Table 6. Distribution of Patients Based on the Presence of Comorbidities
Comorbidities
Present
Absent
Total

Number (N)
45
40
85

Percentage (%)
53
47
100

Based on Table 6, many diabetes mellitus patients at RSUD Prembun had comorbid
conditions, with 45 respondents (53%), while 40 respondents (47%) did not have any
comorbidities. Furthermore, among the patients who had comorbidities, three were
identified as having low medication adherence. This aligns with the findings of Romadhon
et al. (2020), who also observed a correlation between the presence of comorbidities and
reduced adherence among diabetic patients. Supporting this, a study titled "Medication
Adherence in Type 2 Diabetes Mellitus Patients at Puskesmas in East Jakarta" found that
the presence of comorbidities was associated with the highest rate of non-adherence
(45.1%). Rasdianah (2016) emphasized that complex medication regimens tend to reduce
patient adherence, noting that the more frequent the daily medication dose, the lower the
level of adherence. Therefore, simplifying medication regimens is one recommended
approach to improving adherence. The data on Characteristics of Respondents Based on
Duration of Illness can be seen in Table 7.
Table 7 Characteristics of Respondents Based on Duration of Illness
Duration of Illness
≤ 3 years
>3 years
Total

Number (N)
41
44
85

Percentage %)
48.2
51.8
100

Table 7 shows that most patients had been living with diabetes mellitus for more
than three years (44 respondents or 51.8%). Meanwhile, 41 respondents (48.2%) had been
suffering for three years or less. Further analysis revealed that among patients who had
been ill for three years or less, only one exhibited low adherence to medication. Conversely,
among those who had been suffering for more than three years, four respondents
demonstrated low adherence. This suggests a potential pattern where patients with a
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longer duration of illness tend to be less adherent to their treatment. A possible explanation
is that newly diagnosed patients often have higher motivation and stronger expectations
for recovery, which positively influences their adherence. In contrast, long-term sufferers
may experience treatment fatigue, leading to a decline in adherence over time. Yach
(2003b) also highlighted that prolonged illness can negatively impact adherence,
particularly when patients become discouraged or overwhelmed by the chronic nature of
the disease and the complexity of ongoing treatment.
Table 8. Characteristics of Income
Income
< 1 million
1.5 – 3 million
3.5 – 5.5 million
> 5.5 million
Total

Number (N)
69
9
7
0
85

Percentage (%)
81.2
10.6
8.2
0
100

Based on the characteristics of income in table 8, the majority of diabetes mellitus
patients at RSUD Prembun had an income of less than 1 million, with 69 respondents
(81.2%). Meanwhile, 9 respondents (10.6%) had an income between 1.5 and 3 million, and
the remaining 7 respondents (8.2%) earned between 3.5 and 5.5 million. A person's income
is a risk factor for diabetes mellitus and dietary habits. Increased income leads to
socioeconomic changes and a shift in lifestyle, including a higher consumption of fast food
that is not balanced with knowledge and awareness of nutrition. This ultimately results in
high consumption of saturated fats, sugars, low fiber, and insufficient micronutrients,
which causes obesity and triggers the onset of diabetes mellitus (Nanda et al., 2018).
In this study, most of the respondents had an income of less than 1 million.
However, this did not affect adherence because most patients used BPJS Health insurance
for their treatment costs, which alleviates the burden of medical expenses. All diabetes
mellitus patients at RSUD Prembun are encouraged to use BPJS Health to ease the financial
burden, as their treatment requires routine visits and long-term management. The results
of the adherence level based on the MARS-10 questionnaire showed that 80 respondents
(94.1%) had high adherence, while 5 respondents (5.9%) had low adherence. The data on
adherence levels and the relationship between respondent characteristics and adherence
levels can be seen in Tables 9 and 10.
Table 9. Adherence Levels
Adherence Level
High Adherence
Low Adherence
Total

Number (N)
80
5
85

Percentage (%)
94.1
5.9
100

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Table 10. Relationship Between Respondent Characteristics and Adherence Levels
Variable
Age
Gender
Education
Occupation
Number of Medications
Comorbidities
Duration of Illness
Income

p-value
0.769
0.048
0.272
0.921
0.004
0.030
0.026
0.442

Description
Not Significant
Significant
Not Significant
Not Significant
Significant
Significant
Significant
Not Significant

Based on the results of the chi-square test in table 10, it was found that there was
no significant relationship between medication adherence and the characteristics of the
respondents in terms of age, education, occupation, and income, as the p-values were
greater than 0.05. However, there was a significant relationship between gender, number
of medications, comorbidities, and duration of illness, as the p-values were less than 0.05.
CONCLUSION
There is a significant relationship between the level of adherence to oral antidiabetic
medication and patient characteristics, including gender, number of medications,
comorbidities, and duration of illness.
ACKNOWLEDGMENT
The researcher would like to express gratitude to the outpatient department of RSUD
Prembun and Universitas Muhammadiyah Gombong for their support and permission to
conduct the research. This assistance made it possible to complete the research and the
writing of this article.
AUTHOR CONTRIBUTION
ADN: Concepts or ideas; design; definition of intellectual content; literature search;
experimental studies; data analysis; manuscript preparation.
TCW: definition of intellectual content; literature search; experimental studies; data
analysis.
EY: Definition of intellectual content; literature search.
HK: Manuscript editing; manuscript review.
ETHICS APPROVAL
This research had been approved by the ethics commission of Faculty of Health Sciences
Universitas Muhammadiyah Gombong with number of 066.6/II.3.AU/F/KEPK/III/2023.
CONFLICT OF INTEREST (If any)
None to declare.
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