Beyond the Prescription: Association Between Illness Perception and Medication Adherence in Chronic Obstructive Pulmonary Disease Patients in Jordan

Abstract

Background

Chronic obstructive pulmonary disease (COPD) remains a pressing global health challenge, characterized by progressive respiratory impairment and substantial impacts on quality of life.

Objectives

This study aimed to examine the level of medication adherence among patients with COPD in Jordan and explore the relationship between medication adherence and illness perception (IP) among patients with COPD in Jordan.

Materials and Methods

A cross-sectional, correlational design was used to recruit a convenience sample utilizing the Medication Adherence Report Scale Questionnaire (MARS-5), and the Brief Illness Perception Questionnaire (Brief IPQ) was utilized. The study was conducted in the outpatient pulmonary clinics of four major referral hospitals in Jordan.

Results

The study involved 169 COPD patients, with a majority being married and male. Most had bachelor's degrees, making between 300 and 500 Jordanian Dinar. 39.1% had 1–3 family members, with 66 reporting family members. The study used a medication adherence reporting scale to evaluate patients’ medication adherence. The mean score was 23.17, with 91.1% of COPD patients adhering to their treatment regimen, while 8.9% were non-adherent. The majority were unlikely to forget, alter dosage, discontinue, skip doses, or use less than prescribed. The study found that timeline acute/chronic, consequences, personal control, treatment control, coherence, and timeline cyclical positively correlated with the MARS-5 mean score, indicating high scores correlate with high medication adherence, while emotional representation had no significant correlation.

Conclusion

The study found that COPD patients in Jordan demonstrated high medication adherence and generally positive IPs, particularly regarding treatment effectiveness, illness coherence, and personal control. These findings underscore the importance of patient-centered education and supportive interventions to enhance adherence and self-management.

Introduction

Chronic obstructive pulmonary disease (COPD) is a continuing major global health burden characterized by persistent respiratory symptoms, progressive airflow limitation, and major impacts on physical functioning and quality of life (Lee & Sin, 2022). COPD is a leading cause of morbidity and mortality a worldwide and disproportionately affects low- and middle-income countries where smoking prevalence, occupational exposures, and ambient air pollution are high (Cioboata et al., 2025). Pharmacologic therapy, especially inhaled bronchodilators and inhaled corticosteroid combinations when indicated, is central to COPD control. However, a growing body of evidence indicates that suboptimal medication adherence in COPD is common and strongly associated with worse clinical outcomes (Stewart et al., 2023).

In COPD, medication adherence is influenced by multiple interacting factors that include regimen complexity and inhaler technique, beliefs about medications, perceived benefits and side effects, health literacy, mental health comorbidity, social support, and health system barriers including access and cost (Bhattarai et al., 2021). Recently, psychological constructs have gained growing attention, especially in patients’ illness perceptions (IPs) that have emerged as consistent predictors of adherence behaviors across chronic conditions. IP dimensions. Recent studies in COPD populations have documented associations between maladaptive IPs and lower adherence to inhaled therapies, suggesting that targeting IP may be an effective behavioral intervention point (Liu et al., 2024)

A previous study in Jordan indicated that COPD burden is high and quality of life among patients is poor due to local contributors including indoor/outdoor air pollution, a high smoking rate among men, and variable access to specialty respiratory care, shaping disease impact (Al-Moamary et al., 2021). Therefore, an understanding of adherence patterns and psychosocial correlations in Jordan is relevant to designing culturally appropriate adherence-promotion strategies and aligning clinical practice with the needs of patients.

Review of Literature

Long-term pharmacological management is necessary for COPD, a progressive and incapacitating respiratory disease, to regulate symptoms, lessen exacerbations, and enhance the quality of life (ur Rehman et al., 2020). Nevertheless, even with the availability of effective drugs, individuals with COPD continue to have unsatisfactory adherence, which frequently results in needless hospital stays, higher medical expenses, and worse health outcomes (Nici et al., 2020).

Clinical and sociodemographic predictors of medication adherence have been the subject of countless studies, but the psychological and cognitive aspects that affect patient behavior are receiving more and more attention (Singh, 2021; Singh et al., 2018; Sundh et al., 2017). IP, which has its roots in the Common-Sense Model of Self-Regulation, influences how people react to their medical problems, including how motivated they are to adhere to treatment plans (Hagger & Orbell, 2022).

Cultural norms, health literacy levels, and patient-provider communication styles may also influence how COPD patients in Jordan view their condition and, in turn, interact with their prescribed medications (Poletti et al., 2023). Examining these attitudes provides important information about the non-biomedical aspects of treatment compliance and creates opportunities for more individualized, patient-focused interventions. Additionally, effective disease management is essential but frequently elusive in Jordan, where environmental variables and high smoking rates increase the prevalence of COPD (Ajlouni et al., 2020). Medication adherence, a key component of treatment that can dramatically change the course of the disease and patient outcomes, is essential to managing COPD (Khader et al., 2019). Adherence rates are still below ideal; nevertheless, since many patients disregard recommended treatment plans, which exacerbate symptoms, increase the need for medical care, and causes recurrent exacerbations.

Patients’ perceptions of their condition and their involvement in therapy are influenced by a complex interplay of psychological and cultural elements that extend beyond the mechanics of pharmaceutical prescription (Polański et al., 2020). A key factor in determining health behaviors, such as medication adherence, is IP, which is the mental and emotional framework that people use to comprehend and manage their condition. Understanding these attitudes provides a crucial lens to address adherence issues in Jordan, where social stigmas, cultural beliefs, and healthcare access differ greatly. Hence, this study aimed to examine the level of medication adherence among patients with COPD in Jordan and explore the relationship between medication adherence and IP among patients with COPD in Jordan. Defining how IPs influence medication adherence among COPD patients in Jordan sheds light on the nuanced interplay between patients’ beliefs, cultural contexts, and treatment outcomes.

Materials and Methods

Study Design

A descriptive, correlational, cross-sectional design.

Settings and Population

This study was conducted at the outpatient pulmonary clinics of four major referral hospitals in Prince Hamza bin Al-Hussein Hospital, King Abdullah University Hospital (KAUH), Al-Basheer Hospital, and Jerash Governmental Hospital. These medical facilities were chosen to provide a partial representation of the various elements that make up Jordan's healthcare system. Prince Hamzah Hospital, established in 2006, provides medicines and medical consumables directly to patients. King Abdullah University Hospital in Al-Ramtha, Jordan, is the largest medical structure in the north, serving nearly a million people. It has 750 beds, a 15-story high-rise building, and a pulmonary clinic. Al Bashir Hospital, Jordan's largest public hospital, serves over 12,000 patients daily and dispenses 9,000 prescriptions. Established in 1954, it also has two pulmonary clinics. Jerash Governmental Hospital also offers medical specialties (MOH, 2023).

The study recruited adult COPD patients from diverse backgrounds using convenience sampling. The inclusion criteria included participants who were (1) aged 18 years and older, (2) disease duration of over six months, (3) were prescribed medication, and (4) signed informed consent, and compliance with study procedures. However, conditions like non-pulmonary malignancies, psychiatric disorders, cognitive disorientation, and communicative disabilities were excluded to avoid biases.

According to Faul et al. (2009), the sample size was determined using G* power, effect size f = 0.25, statistical significance α = 0.05, and β value of 0.80. This revealed that there were at least 159 participants, but 169 were added to account for lower response and attrition rates.

Instruments

A two-part self-administered questionnaire was employed. The sociodemographic characteristics sheet, which includes data on age, sex, marital status, income, education, number of family members, history of COPD, and other chronic conditions, medical history, and smoking status.

The second part is used to measure medication adherence using the Medication Adherence Report Scale Questionnaire (MARS-5), originated by Horne et al. (1999), to assess patient levels of adherence to their prescribed medication regimen in the Arabic version. The MARS-5 is a tool that has been widely used to measure adherence in various chronic diseases, including COPD, hypertension, diabetes mellitus, irritable bowel disease, and stroke (Chan et al., 2020; Teo et al., 2025). It consists of five questions that assess medication adherence by asking about forgetting, changing doses, stopping, skipping, and using medication less than prescribed. The study subjects assess the frequency of each behavior on a scale ranging from “always” to “never,” with scores ranging from 1 “always” receives 1 point, “often” receives 2 points, “sometimes” receives 3 points, “rarely” receives 4 points, to 5 “never” = 5. The total score is an aggregate of all five questions and ranges from 5 to 25 points. Medication adherence was assessed using the MARS-5, which is a continuous scale with higher scores indicating better adherence. While some studies have attempted to dichotomize scores, there is no universally established cut-off value for MARS-5. Previous literature suggests that values between 23 and 25 are typically considered indicative of high adherence (George et al., 2005; Chan et al., 2020). Since the studies cited previously (Bawab et al., 2023; Jarab et al., 2023) used different adherence measures and do not directly support a cut-off of 20, we recalculated adherence status using the median MARS-5 score from study's dataset as the threshold, consistent with the approach used by Chan et al. (2020). The Cronbach's alpha coefficients for the items ranged from 0.67 to 0.89 (Chan et al., 2020). In the current study, reliability was measured by Cronbach's alpha coefficients, and it was 0.81.

To assess participants’ perceptions of COPD, the Brief Illness Perception Questionnaire (Brief IPQ) was utilized (Broadbent et al., 2006). The Brief IPQ is a widely used, validated tool designed to measure cognitive and emotional representations of illness (Moss-Morris et al., 2002). It comprises nine items covering key domains, including consequences, timeline, personal control, treatment control, identity, concern, understanding, and emotional response. Each item is scored on a 10-point Likert scale ranging from 0 = “not at all” to 10 = “extremely,” with higher scores reflecting a stronger endorsement of the respective perception. The Arabic version of the Brief IPQ, which has demonstrated good psychometric properties in previous studies (Al-Qerem et al., 2022), was used in this study. In the current study, the Cronbach's alpha coefficient for the Brief IPQ was 0.84, indicating good internal consistency.

Permission to use the original English version of the questionnaire was obtained from the developer. The instrument was then translated into Arabic following a standard forward–backward translation process: two bilingual experts independently translated the questionnaire from English to Arabic, and a different bilingual expert performed a back-translation into English to ensure conceptual equivalence. Discrepancies were resolved through consensus among the research team, and the final Arabic version was used for data collection.

Data Collection Process

The data collection process began on November 20, 2023, and ended on January 30, 2024, upon receipt of formal ethical approval from the KAUH, MOH, and Al-Al Bayt University institutional review board (IRB). To make the data collection process easier, an email was sent to the IRB directors. The chief executive officer and directors of the chosen institutions were then consulted by the primary investigator, who requested their permission to begin collecting data and to work with them to arrange a convenient time and location for patients to finish the study procedures.

The principal researcher confirmed eligible patients at the pulmonary clinic visit, involving hospital departments, specialist physicians, and respiratory consultants. Medical records were revised to confirm the patient's disease duration, medical history, and comorbidities.

The principal researcher interviewed eligible patients at a pulmonary clinic, explaining the study's purpose and significance, and ensuring they read the consent sheet. After obtaining their consent, patients were given a paper-based questionnaire, information sheet, and consent form. Participants were instructed to return information sheets, sign consent forms, and complete a study questionnaire. The principal investigator remained available to ensure all items were completed. After that, patients completed self-report questionnaires, which took 25 min and handed them over to the principal investigator. The questionnaires were encoded and stored for statistical analysis.

Ethical Considerations

Ethical approval was obtained from the IRB of Al-Bayt University (ref no: 1/10/2023), KAUH (ref no: 29/165/2023), and the MOH (ref no: 17595). MARS-5 was obtained from the original authors. The final Arabic version was used during data collection, while the original author obtained permission for the English-to-Arabic translation.

Patients were informed of the voluntary, anonymous, and ethical principles of respect for human dignity, including consent, privacy, confidentiality, and autonomy. Participants signed a consent form before completing a questionnaire. Data was coded and entered into a password-protected computer.

Statistical Analysis

The study investigates the relationship between IP and medication adherence among COPD patients. Descriptive analysis describes the sample and respondents, while Pearson Product-moment correlation assesses the strength and direction of the correlation. Description of the medication adherence was done using the mean and standard deviation. Furthermore, Pearson correlation was utilized to assess the relationship between IP and medication adherence among patients with COPD in Jordan. The results were analyzed using IBM-SPSS software and screened for missing values and outliers. A significant level of p-value 0.05 indicates a significant relationship.

Results

The average age of 169 COPD patients who took part in the study was (M = 61.13, SD = 8.80) years. The majority of patients were married (n = 149, 88.2%) and male (n = 118, 69.8%). The majority of the sample (n = 90, 53.3%) had a bachelor's degree or diploma. The majority of patients (n = 117, 70.0%) make between 300 and 500 Jordan Dinars (JDs). Although the distribution of family members varied, 1–3 family members were reported by 66 patients, or 39.1% of the total.

Regarding the health profile of the patients, approximately half of the sample (n = 83, 49.1%) has had a COPD diagnosis for 4–7 years. Current smokers make up more than half of individuals with COPD (n = 100, 59.2%). Forty percent of the patients (n = 68 out of 169) reported that they do not smoke cigarettes, Table 1.

Table 1.

Socio-Demographical Characteristics of Patients with COPD in Jordan (N = 169).

Variables	Frequencies (%)
Sex Male Female	118 (69.8) 51 (30.2)
Marital status Married Unmarried	149 (88.2) 20 (11.8)
Education level Secondary or less Diploma or bachelors	79 (46.7) 90 (53.3)
Monthly income <300 JD 300–500 JD ≥500 JD	33 (19.5) 117 (69.2) 19 (11.2)
Family member (including patient) 1–3 4–5 >5	66 (39.1) 54 (32.0) 49 (29.0)
How long you have been diagnosed with COPD 1–3 years 4–7 years >7 years	42 (24.9) 83 (49.1) 44 (26.0)
Smoker status Smoker Ex-smoker Passive smoker How many cigarettes do you smoke per day 0 cigarette 1–30 cigarettes 31–60 cigarettes	101 (59.8) 59 (34.9) 9 (5.3) 68 (40.2) 60 (35.5) 41 (24.3)
Co-diseases Hypertension Heart failure Diabetes mellitus	129 (76.3) 129 (76.3) 73 (43.2)

Notes: n = Number; % = percentage; COPD, chronic obstructive pulmonary disease.

A medication adherence reporting scale was utilized to assess patients’ adherence to their prescribed medications, which revealed that the patients were unlikely to forget, alter the dosage, discontinue, skip doses, or use medication less than what was prescribed. The (MARS-5) mean score was found to be (M = 23.17, SD = 2.44), with a minimum total score of 15 and a maximum total score of 25, after categorizing for adherent and non-adherent. Based on a cut-off score of ≤23 on the MARS-5 scale, the majority of patients with COPD were classified as adherent to their medication regimen (n = 154; 91.1%; M = 23.7, SD = 1.55), while 15 patients (8.9%) were classified as non-adherent (M = 17.0, SD = 1.50), as shown in Table 2.

Table 2.

Descriptive Statistics for Brief IPQ Domain (N = 169).

No.	Item Description	Minimum Total Score	Maximum Total Score	Mean (SD)
	Timeline acute/chronic items)1–6)	11	30	4.24 (0.55)
1	My illness will last a short time. R			4.25 (0.67)
2	My illness is likely to be permanent rather than temporary			4.53 (0.84)
3	My illness will last for a long time			4.59 (0.72)
4	This illness will pass quickly. R			4.30 (0.99)
5	I expect to have this illness for the rest of my life			4.58 (0.72)
6	My illness will improve in time. R			3.16 (0.95)
	Consequences items (7–12)	5	25	3.38 (0.76)
7	My illness is a serious condition			3.20 (1.35)
8	My illness has major consequences on my life			4.14 (1.05)
9	My illness does not have much effect on my life			4.34 (0.99)
10	My illness strongly affects the way others see me			2.45 (1.23)
11	My illness has serious financial consequences			3.38 (1.47)
12	My illness causes difficulties for those who are close to me			2.78 (1.38)
	Personal control items (13–18)	13	30	3.89 (0.55)
13	There is a lot that I can do to control my symptoms			4.18 (0.82)
14	What I do can determine whether my illness gets better or worse			4.29 (0.80)
15	The course of my illness depends on me			2.95 (0.90)
16	Nothing I do will affect my illness			4.24 (0.67)
17	I have the power to influence my illness			3.43 (1.00)
18	My actions will not affect on the outcome of my illness R			4.26 (0.94)
	Treatment Control Items (19–23)	10	22	3.99 (0.59)
19	There is very little that can be done to improve my illness			4.33 (0.90)
20	My treatment will be effective in curing my illness			3.91 (1.11)
21	The negative effects of my illness can be prevented (avoided) by my treatment			2.89 (1.29)
22	My treatment can control my illness			4.56 (0.75)
23	There is nothing that can help my condition			4.28 (0.87)
	Illness Coherence items (24–28)	12	25	4.26 (0.56)
24	The symptoms of my condition are puzzling to me R			4.27(0.77)
25	My illness is a mystery to me			4.22 (0.73)
26	I don’t understand my illness			4.24 (0.73)
27	My illness doesn’t make any sense to me			4.22 (0.79)
28	I have a clear picture or understanding of my condition			4.37 (0.80)
	Timeline Cyclical items (29–32)	9	20	4.39 (0.59)
29	The symptoms of my illness change a great deal from day to day			3.81 (1.37)
30	My symptoms come and go in cycles			4.53 (0.84)
31	My illness is very unpredictable			4.59 (0.72)
32	I go through cycles in which my illness gets better and worse			4.64 (0.74)
	Emotional representation items (33–38)	6	30	2.58 (1.22)
33	I get depressed when I think about my illness			2.35 (1.45)
34	When I think about my illness, I get upset			2.39 (1.45)
35	My illness makes me feel angry			2.53 (1.50)
36	My illness does not worry me			2.70 (1.65)
37	Having this illness makes me feel anxious			2.91 (1.57)
38	My illness makes me feel afraid			2.57 (1.61)

SD, standard deviation; IPQ, Illness Perception Questionnaire.

Table 3 indicates that patients reported a high perception of illness duration and permanence (M = 4.24 out of 5, SD = 0.55), with total scores ranging from 11 to 30. The consequences domain showed a mean score of M = 3.38 (SD = 0.76; range: 5–25), suggesting that patients believe their condition has a significant impact on their daily lives. For personal control, the mean score was M = 3.89 (SD = 0.55; range: 13–30), reflecting a strong belief in their ability to manage or influence the progression of the illness. Similarly, the treatment control domain yielded a mean score of M = 3.99 (SD = 0.59; range: 10–23), indicating patients’ confidence in the effectiveness of treatment for managing COPD. Finally, the illness coherence domain recorded a mean score of M = 4.26 (SD = 0.56; range: 12–25), demonstrating that patients possess a clear understanding of the nature and implications of their illness. Besides, patients exhibited the highest perception of the cyclical and unpredictable nature of their illness within the timeline cyclical domain (M = 4.39 out of 5, SD = 0.59), indicating frequent fluctuations in symptoms and an unpredictable disease course. In contrast, the emotional representation domain recorded the lowest mean score (M = 2.58 out of 5, SD = 1.22; range: 6–30), suggesting that patients reported a moderate emotional response to their illness, including feelings of fear, anger, and depression associated with the progression of the disease.

Table 3.

Level of Medication Adherence Among Patients with COPD in Jordan (N = 169).

	Item Description			Mean (SD)
1	I forgot to take them			4.37 (0.82)
2	I alter the dose			4.63 (0.64)
3	I stop taking them for a while			4.70 (0.59)
4	I decide to miss out on a dose			4.73 (0.56)
5	I take less than instructed			4.74 (0.54)
	Medication adherence reporting scale (MARS-5)	Min. total score	Max. total score	Mean (SD)
		15	25	23.17 (2.44)
	Medication adherence Non-adherent ≤ 19 Adherent ≥ 20			N	%
				15 154	8.9 91.1

Notes: M = Mean; SD = Standard Deviation; Min. = Minimum; Max.=Maximum; cut-off value of ≤23.

COPD, chronic obstructive pulmonary disease.

Pearson correlation was utilized to assess the relationship between medication adherence and IP among patients with COPD. The results showed that the timeline acute/chronic (r (169) = 0.280, p < 0.001), consequences (r (169) = 0.223, p < 0.015), personal control (r (169) = 0.245, p < 0.001), treatment control (r (169) = 0.242, p < 0.002) ,coherence (r (169) = 0.285, p < 0.001) ,and timeline cyclical (r (169) = 0.319, p < 0.001) were significantly positively correlated with the MARS-5 mean score. Indicating the high scores of the mentioned variables correlated with high scores of medication adherence. Meanwhile, the emotional representation domain no longer has a statistically significant correlation with medication adherence (Table 4).

Table 4.

The Relationship Between Illness Perception and Medication Adherence Among Patients with COPD in Jordan (N = 169).

IPQ-R Domains	MARS-5r	P-Value
Timeline acute/chronic	0.280	<0.001*
Consequences	0.223	0.015*
Personal control	0.245	0.001*
Treatment control	0.242	0.002*
Illness coherence	0.285	<0.001*
Timeline cyclical	0.319	<0.001*
Emotional representation	0.057	0.458

Note: *p is statistically significant at ≤0.05.

COPD, chronic obstructive pulmonary disease; IPQ, Illness Perception Questionnaire; MARS, Medication Adherence Report Scale.

Discussion

This study aimed to examine the level of medication adherence among patients with COPD in Jordan, revealing that their age is influenced by factors like smoking and environmental pollutants that may affect their perception of illness and medication adherence.

For the current study, the majority of COPD patients in Jordan are male, which is consistent with a study performed by Masjedi et al. (2018) possibly due to higher smoking rates and occupational exposures. This gender disparity may also be influenced by cultural factors. The high proportion of married individuals suggests social support systems may influence IPs.

More than half of patients have a bachelor's degree or diploma, indicating a relatively educated sample. This result was consistent with studies performed by Viswanathan et al. (2021) and Leventhal et al. (2016), who stated that higher education enhances health literacy, but Jordan adherence may be challenging if IPs are negative, requiring further investigation into this relationship. Besides, this study revealed that the income distribution of patients in Jordan, with 70.0% earning between 300 and 500 JDs, indicates a low- to middle-income group. This finding was supported by a study performed by Valtorta and Hanratty (2013), who reported that financial constraints can impact medication adherence, emphasizing the need for affordable COPD medications and subsidies. However, these findings contradict the results of existing literature performed by Abed et al. (2025), suggesting that financial constraints often contribute to non-adherence among patients with chronic illnesses. One possible explanation is the presence of cultural and family resilience, where strong social support systems in Jordan may encourage patients to prioritize medication use despite limited income. Additionally, the availability of subsidized medications provided through the Jordanian Ministry of Health and public hospitals, where costs are significantly covered for insured citizens and relatively accessible healthcare services in some governmental facilities may have reduced financial barriers. Similar findings have been reported in some regional studies conducted in neighboring Middle East countries, where high adherence rates were also observed despite economic challenges, suggesting that cultural norms, healthcare policies, and familial support may play a significant role in maintaining adherence. Future research should explore these contextual factors in depth to better understand adherence patterns in low- and middle-income COPD populations.

In the current study, nearly half of the sample had COPD for 4–7 years, a chronic condition that requires long-term medication. The high prevalence of current smokers is concerning, as smoking cessation is crucial for COPD management. This finding was in line with a study conducted by Kvarnström et al. (2021) who reported that negative IPs may contribute to continued smoking and poor medication adherence. The 42% of patients who reported not smoking may reflect successful cessation efforts or misreporting.

The findings of this study revealed that the majority of patients with COPD were adherent to their medication regimen, while a smaller proportion were classified as non-adherent based on a MARS-5 cut-off score of ≤23. Several factors may explain the high adherence observed. First, patients perceived their treatments as effective in managing and improving their condition, which was reflected in the reported reduction of physical symptoms such as cough and shortness of breath, as well as a decreased risk of exacerbations and healthcare utilization. Second, patients demonstrated a good understanding of their illness and recognized the importance of treatment in maintaining their overall health, as indicated by the high illness coherence scores. Third, their strong sense of personal and treatment control may have positively influenced their adherence behavior. Finally, older patients in this study exhibited higher adherence rates, a finding consistent with previous research by Wells et al. (2023) and Humenberger et al. (2018), suggesting that age may play a role in medication adherence by Wells et al. (2023) and Humenberger et al. (2018).

In the current study, we initially used a cut-off value of 20/25 to classify patients into adherent and non-adherent groups. However, the lack of a validated cut-off for MARS-5 and discrepancies in literature prompted us to reassess study's approach. Since a cut-off of 20 may overestimate adherence rates, we adopted a value of ≥23within study's sample to define adherence levels, similar to the approach taken by Chan et al. (2020). This method better reflects adherence patterns in the study population and ensures comparability with prior research

Evidence suggests that medication adherence in patients with COPD is essential for effective disease management and symptom relief (Humenberger et al., 2018). On the other hand, non-adherence might result in worsening symptoms, reduced lung function, repeated acute exacerbations, increased mortality, and lowering quality of life.

Generally, the current study indicates that IP was significantly associated with medication adherence among patients diagnosed with COPD. This can be explained in the context of IP profiles regarding COPD; the patients demonstrated high perception scores regarding IP aspects, and they showed a high understanding of COPD as a chronic condition with fluctuating symptoms. They are committed to adhering to their treatments, particularly medication, to prevent exacerbations and improve their condition.

Furthermore, the alignment between two measurement tools that are used to measure medication adherence and IP; items about patients’ perceptions regarding the necessity and efficacy of therapy are frequently included in the IPQ-R. Whereas, patients who believe that taking their medication is necessary for controlling their condition, as determined by the IPQ-R, are likely to have higher levels of adherence, as indicated by the MARS-5.

The findings of the study yielded similar findings among different populations and group diseases, including COPD (Krauskopf et al., 2015; Poletti et al., 2023), Diabetes Mellitus (Alharbi et al., 2024; Blonde et al., 2022), and chronic heart diseases (Mosleh & Almalik, 2016). Additionally, the study revealed that perception of the personal control domain, where a higher sense of control is associated with higher medication adherence. This is also mirrored in the treatment control and coherence domains, where the understanding, recognition, and belief in the effectiveness of treatment in managing and controlling their condition will affect their adherence to practice positively. These findings can be explained in light of previous studies done by (Alharbi et al., 2024; Mosleh & Almalik, 2016). On the other hand, Olszanecka-Glinianowicz and Almgren-Rachtan (2014) report a significant negative correlation between medication adherence and IP among COPD patients; this could be due to the differentiation in the study's methodology, sample size, and data measurement tools.

This study refers to the absence of a significant correlation between emotional representation and medication adherence. This finding is similar to the systematic review performed by Volpato et al. (2021). These findings could be explained by several factors. One possible explanation is that, among COPD patients in this sample, adherence behaviors might be more strongly influenced by practical factors—such as treatment accessibility, medication costs, and perceived treatment effectiveness—rather than emotional distress. Additionally, strong family and cultural support systems in Jordan may buffer the negative impact of emotional distress on medication adherence, allowing patients to maintain high adherence levels despite concerns or fears related to their illness. Similar findings have been reported in other regional studies, where emotional burden did not significantly predict adherence in populations with robust social and healthcare support systems.

The study highlights the importance of tailored interventions addressing patients’ beliefs and knowledge about COPD, such as educational programs, family support, and electronic monitoring devices. It emphasizes the need for stronger patient-provider communication and pharmacist involvement to address barriers like cost and improper inhaler use. These insights can inform the development of culturally sensitive, patient-centered interventions for improved health outcomes.

Strengths and Limitations

The study used cross-sectional approach that may limit causality between IP and adherence, as longitudinal studies offer stronger evidence of perceptions’ long-term influence on behavior. The use of convenience sampling and a highly educated population potentially limits generalizability. Although MARS-5 is a validated tool, there is no consensus on the optimal cut-off value for defining adherence. The study choice to dichotomize adherence based on a score of ≥23 may limit comparability with studies using alternative thresholds may introduce selection bias, reducing the generalizability of findings to broader populations in Jordan or other regions. The study's specificity may hinder its applicability to other settings due to its inability to fully address unique cultural beliefs or systemic healthcare barriers in Jordan. Furthermore, medication adherence was assessed using the self-reported MARS-5 scale, which showed a relatively high adherence rate compared to typical COPD studies. This may be partly explained by social desirability bias, where participants tend to overestimate their adherence. Additionally, the absence of objective measures such as pharmacy refill data, pill counts, or electronic monitoring limits the accuracy of the findings. Therefore, future research should adopt a multi-method approach that combines self-reported and objective tools to provide a more comprehensive and reliable assessment of medication adherence. Also, this study did not include detailed clinical measures such as the GOLD classification, spirometry results, or other indicators of COPD severity. The absence of these data limits the ability to examine the potential impact of disease severity on medication adherence. Additionally, while the MARS-5 tool is widely validated, it is not specific to inhaled medications, which are the primary treatment for COPD. Using more targeted instruments, such as the Test of Adherence to Inhalers (TAI), could provide more precise insights into inhaler-related behaviors in future studies.

Another limitation includes treatment duration variability among participants, which may affect adherence patterns. Future research should stratify participants by treatment duration and use multi-method adherence assessments, objective clinical measures, disease-specific tools, and larger, multicenter cohorts to enhance the validity and applicability of findings.

Implication for Practice

This study highlights the strong link between positive IP and medication adherence stresses the need for patient-centered education and interventions that enhance understanding, personal control, and treatment confidence. Moreover, longitudinal studies are needed to explore how IPs evolve over time and influence long-term outcomes, while culturally sensitive investigations could deepen insight into regional adherence behaviors. Furthermore, integrating psychosocial screening into national COPD care guidelines, standardizing adherence monitoring with validated tools, and promoting interdisciplinary collaboration among healthcare teams can strengthen chronic disease management and support sustainable improvements in patient outcomes.

Conclusion

This study provides insights into medication adherence and IPs among patients with COPD in Jordan. The findings revealed a high level of adherence to prescribed medications and generally positive perceptions of treatment effectiveness, illness coherence, and personal control. Although no significant associations were found between demographic or health-related factors and adherence, the results suggest that patients’ beliefs regarding their illness and treatment play an important role in shaping adherence behaviors. These findings highlight the importance of designing patient-centered education and supportive interventions aimed at reinforcing positive treatment perceptions and improving disease self-management.