Impact of Pharmacist-Led Diabetes Education on Medication Adherence in Community Pharmacies

Thesis Abstract

This study investigates how pharmacist-led diabetes education in community pharmacies influences medication adherence among adults with type 2 diabetes, addressing the persistent gap between prescribed regimens and patient adherence that adversely affects glycemic control and compels higher healthcare costs. The aim is to evaluate the effectiveness of structured pharmacist interventions on adherence behaviors and explore underlying mechanisms that mediate this effect. Specific objectives are to (1) quantify changes in Medication Adherence Report Scale (MARS-5) scores over a six-month period following education; (2) examine the impact on objective refill adherence using Proportion of Days Covered (PDC) derived from pharmacy dispensing records; (3) identify patient-level mediators such as health literacy, self-efficacy, and diabetes knowledge; (4) assess patient and pharmacist experiences to elucidate feasibility and acceptability; and (5) determine whether improvements differ by age, sex, duration of diabetes, and prior adherence levels. A mixed-methods, prospective, multi-site quasi-experimental design will be employed. The study will recruit 400 adults with type 2 diabetes from 20 community pharmacies, randomized at the pharmacy level to either an intervention or usual care arm to avoid contamination. The intervention comprises a standardized, pharmacist-led education program delivered at baseline and reinforced at 1, 3, and 5 months, incorporating motivational interviewing, goal setting, and personalized regimen simplification, aligned with social cognitive theory and the Health Belief Model to address beliefs, self-efficacy, and perceived barriers. Data collection will include quantitative measures MARS-5 and Morisky-Green Adherence Scale for self-reported adherence, PDC from pharmacy records for objective adherence, HbA1c values at baseline and six months, and surveys assessing health literacy (Newest Vital Sign), diabetes knowledge (Diabetes Knowledge Test), and self-efficacy (Diabetes Management Self-Efficacy Scale). Qualitative data will be gathered via semi-structured interviews with a purposive sample of 40 patients and 20 pharmacists to explore experiences, acceptability, and perceived mechanisms of change. Validity and reliability of instruments will be established through prior validation references and pilot testing; questionnaires will be pilot-tested with 40 participants, and inter-rater reliability for interview coding will be assessed using Cohen’s kappa. Data analysis will integrate quantitative and qualitative strands. Descriptive statistics will summarize participant characteristics. Repeated-measures ANOVA and mixed-effects regression models will assess changes in adherence scores over time and differences between arms, controlling for covariates. Logistic regression will model odds of achieving adequate PDC (?80%). Mediation analyses, following the PROCESS macro framework, will test whether health literacy, self-efficacy, and diabetes knowledge mediate the relationship between the pharmacist education intervention and adherence outcomes. HbA1c changes will be analyzed using linear mixed models to explore clinical relevance. Qualitative data will be analyzed thematically using NVivo, with coding grounded in the theoretical constructs of the social cognitive theory and Health Belief Model to triangulate and explain observed quantitative effects. An integrated interpretation will synthesize convergent and divergent findings to delineate mechanisms and contextual factors influencing adherence. Expected findings include statistically significant improvements in self-reported adherence (mean MARS-5 increase of at least 1.0 point, p<0.05) and higher PDC (?90%) in the intervention group versus control, accompanied by meaningful reductions in HbA1c (?0.5 percentage points). Mediation analyses are anticipated to show that enhanced self-efficacy and diabetes knowledge partially mediate the adherence improvements, with health literacy moderating the strength of the intervention effects. Qualitative insights are expected to reveal acceptability of pharmacist-led education, perceived personalization, and practical barriers such as time constraints and systemic fragmentation. The study contributes to knowledge by empirically detailing how pharmacist-delivered education within community pharmacies can elevate adherence and improve glycemic outcomes, and by identifying mediators and contextual factors that enhance or impede effectiveness. Policy and practice implications include the potential integration of standardized pharmacist education modules into routine care, allocation of time and reimbursement for structured counseling, and the refinement of patient-tailored strategies to sustain adherence gains. The main conclusion posits that pharmacist-led diabetes education in community pharmacies, underpinned by established behavioral theories and delivered with fidelity, can produce meaningful adherence improvements and clinical benefits, provided that practitioners are supported with training, resources, and organizational backing to address patient-specific barriers. Recommendations include scalable implementation with monitoring, incorporation of digital reminders, and further research into long-term sustainability and cost-effectiveness across diverse populations.