The recent 2025 scientific statement from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) and the ESC Working Group on Cardiovascular Pharmacotherapy (DOI: 10.1002/ejhf.70090) spotlights this issue, framing non-adherence through six interconnected dimensions: patient-related, therapy-related, condition-related, system-related, socioeconomic-related, and environmental-related. This model builds on the World Health Organization’s (WHO) classic five dimensions by adding an environmental lens to capture geographical and logistical challenges.
But how does a provider move from detection—often via tools like the 8-item Morisky Medication Adherence Scale (MMAS-8)—to actionable improvement? Enter strategies inspired by the Morisky Adherence Action Plan (MAAP), a proven framework from moriskyscale.com designed to assess adherence, predict risks, and craft personalized interventions. MAAP, which leverages the Morisky scales (e.g., MMAS-8) to categorize adherence as low, medium, or high while pinpointing intentional or unintentional barriers, aligns seamlessly with the ESC’s multidimensional approach. By adapting MAAP’s core steps—assessment, risk prediction using WHO-like dimensions, action planning with targeted education and support, and ongoing measurement—providers can systematically uncover and address each of the six dimensions. This not only boosts GDMT persistence (e.g., from a dismal 5–67% in real-world data) but also enhances outcomes like reduced mortality and readmissions.
Let’s dive into a step-by-step guide for providers: After flagging non-adherence with MMAS-8 (a quick, validated self-report tool scoring 0–8, where <6 signals issues), use targeted questioning, history-taking, and multidisciplinary input to explore the dimensions. Then, deploy MAAP-inspired tactics: personalize interventions, educate on barriers, monitor progress, and adjust plans dynamically. Here’s how it plays out for each dimension in HF care.
Patient-Related Dimension: Beliefs, Behaviors, and Beyond
This dimension encompasses personal factors like forgetfulness, low self-efficacy, depression, cognitive impairment, or misconceptions about medications (e.g., “I feel fine, so I don’t need my beta-blocker”). Providers can uncover it by following up MMAS-8 results with open-ended questions: “What makes it hard to remember your pills?” or “Do you worry about long-term effects?”
MAAP-inspired strategies: Start with risk prediction—use MMAS-8 domains to classify intentional (e.g., stopping when feeling better) vs. unintentional (e.g., forgetting) non-adherence. Develop a personalized action plan with education sessions (≥3 face-to-face or virtual) to reframe beliefs, build self-efficacy through goal-setting, and integrate mental health support (e.g., screening for depression, which predicts poorer adherence). Involve caregivers for cognitive challenges. Monitor via follow-up MMAS-8 scores, aiming for incremental improvements that could cut death risks by 2–11%.
Therapy-Related Dimension: Regimen Complexity and Side Effects
Here, barriers stem from the treatment itself—polypharmacy (HF patients often juggle 5+ meds), frequent dosing, or side effects like fatigue from beta-blockers or hypotension from ARNi. Uncover by asking: “Do side effects bother you?” or reviewing refill patterns for inconsistencies.
Drawing from MAAP: After assessment, predict risks tied to regimen burden and craft interventions like simplifying to once-daily options or de-prescribing non-essentials. A standout tactic: Advocate fixed-dose polypills (combining GDMT elements), which MAAP endorses for reducing pill counts by ~31% and enhancing compliance. Provide targeted education on managing side effects, and collaborate with pharmacists for routine reviews. Measure success through objective metrics like Proportion of Days Covered (PDC ≥80%), tracking reduced adverse events.
Condition-Related Dimension: Disease Burden and Comorbidities
HF’s symptom severity, progression, or comorbidities (e.g., CKD limiting SGLT2i dosing, COPD complicating breathing meds) can erode adherence. Probe with: “How do your symptoms affect your ability to take meds?” or assess via tools like the European Heart Failure Self-care Behaviour Scale (EHFScB-9).
MAAP alignment: Use the framework’s risk prediction to link condition factors to non-adherence domains. Action plans might include multidisciplinary tailoring—e.g., remote monitoring (as in TIM-HF2 trials, cutting events by 20–30%) to adjust therapies amid flares. Educate on connecting adherence to symptom relief for motivation, and involve specialists for comorbidities. Ongoing measurement ensures adaptations, fostering better self-care in chronic HF.
System-Related Dimension: Care Delivery Gaps
Fragmented follow-ups, poor provider communication, or access hurdles fall here. Uncover through history: “How often do you see your doctor?” or by noting missed appointments in records.
MAAP strategies: Post-assessment, predict system risks and build action plans with enhanced support—embed routine adherence checks (e.g., MMAS-8 in workflows) and deploy multidisciplinary teams (nurses, pharmacists) for frequent contacts and reconciliation. Digital tools like apps or text reminders mirror MAAP’s monitoring emphasis, improving engagement. Measure via utilization data, targeting 15–20% adherence gains.
Socioeconomic-Related Dimension: Financial and Educational Barriers
Costs (e.g., co-pays dropping adherence per $7.80 increase), low health literacy, or education gaps amplify risks. Ask: “Is cost a concern?” or screen literacy with simple tools.
Inspired by MAAP: Risk prediction highlights these as WHO-style social/economic factors. Interventions include cost-relief programs, affordable alternatives (e.g., ACEi over ARNi), and culturally sensitive education with visuals. MAAP’s personalized plans ensure monitoring for equity, reducing disparities in vulnerable groups like the elderly or low-income patients.
Environmental-Related Dimension: Logistical and Geographical Challenges
The ESC’s innovative addition covers rural-urban disparities, social isolation, language barriers, or cultural beliefs. Uncover: “Does distance to your pharmacy affect refills?” or assess support networks.
MAAP adaptation: While MAAP uses five WHO dimensions, extend its framework by incorporating environmental risks into action plans—e.g., telehealth for remote access, community programs, or family involvement to combat isolation. Provide tailored education addressing cultural factors, and monitor with digital ecosystems to bridge gaps, aligning with MAAP’s goal of holistic, measurable improvements.
From Insight to Impact: Implementing MAAP in Practice
By weaving MAAP’s structured approach—assess with MMAS-8, predict multidimensional risks, plan personalized fixes, and measure outcomes—providers can transform non-adherence from a hidden threat to a conquered challenge. In HF, this means fewer crises, better quality of life, and cost savings that outweigh interventions. Tools like MMAS-8, available for licensing at moriskyscale.com, make it accessible for clinics, trials, or chronic care (e.g., Medicare CPT 99490).
Ready to elevate adherence? Visit moriskyscale.com to explore MAAP and MMAS resources today. Share your experiences in the comments—what’s one dimension you’ve tackled successfully?
Note: Always consult the full ESC statement

The 2025 ESC scientific statement on adherence to guideline-directed medical treatments in heart failure (DOI: 10.1002/ejhf.70090) primary focus on validated tools appears in Box 1 (“Practical tools for measuring adherence”), which lists a small set of practical, evidence-based options suitable for clinical practice and research in HF populations. These are intended to help identify non-adherence overall and uncover potential barriers across dimensions, rather than being dimension-specific:

1. ​Morisky Medication Adherence Scale (MMAS-8)
2. European Heart Failure Self-care Behaviour Scale (EHFScB-9)
3. Pharmacy refill data

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ESC recommends addressing each of the six dimensions:
​• Patient-related factors (e.g., beliefs, forgetfulness, low self-efficacy, depression/anxiety, cognitive impairment, age/sex differences):
Empower patients through structured education (≥3 face-to-face or home-based sessions, extended to caregivers) to build understanding of HF, medication rationale, and self-care skills. Promote shared decision-making and self-efficacy to foster ownership. Address mental health via integrated psychological support, as depression strongly predicts poorer adherence. Use simple tools like digital reminders/apps for forgetfulness and involve caregivers for elderly or cognitively impaired patients.
• Therapy-related factors (e.g., polypharmacy, complex regimens, side effects like hypotension/fatigue, frequent dosing):
Simplify treatment wherever possible—prioritize once-daily dosing, long half-life agents, or de-prescribing unnecessary drugs. Strongly advocate fixed-dose polypills (single-pill GDMT combinations) for stable patients after achieving target doses, which reduce pill burden, minimize confusion, and improve adherence by ~31% while lowering mortality risk by ~10% in cardiovascular settings. Routine medication reviews by pharmacists help manage side effects and up-titration tolerability.
• Condition-related factors (e.g., symptom severity, comorbidities like CKD/COPD/cognitive disorders, disease progression):
Tailor GDMT adjustments via multidisciplinary teams and remote monitoring to enhance tolerability amid comorbidities. Educate patients on linking symptom relief/improvement to therapy adherence for motivation. Involve specialists (e.g., geriatricians) and use real-time data from digital tools to adapt therapies proactively, reducing adverse reactions from polypharmacy.
• System-related factors (e.g., limited follow-up, fragmented care, provider overestimation of adherence, access barriers):
Embed routine adherence assessment (e.g., proportion of days covered <80% threshold, self-report tools like MMAS-8) into clinical workflows. Deploy multidisciplinary teams (nurses, pharmacists, specialists) for frequent contacts, education, up-titration support, and medication reconciliation—shown to boost adherence by 15–20%. Integrate digital ecosystems (text reminders, apps, remote monitoring like in the TIM-HF2 trial) for ongoing support and event reduction (up to 20–30% fewer HF events).
• Socioeconomic-related factors (e.g., financial constraints, low health literacy/education, insurance gaps):
Mitigate cost barriers through reduced co-payments, free medications where feasible, patient assistance programs, or affordable alternatives (e.g., ACEi/ARB when ARNi is unaffordable). Use simplified, culturally sensitive communication with visual aids for low-literacy groups. Screen for socioeconomic risks during assessments and advocate policy changes for better formulary access.
• Environmental-related factors (e.g., rural-urban access disparities, logistical challenges, social isolation, cultural/religious beliefs, language barriers):
Leverage community-based programs and digital solutions (apps, telehealth, text reminders) to overcome geographical isolation and improve access in underserved areas. Strengthen social support networks via caregiver/family involvement and culturally tailored education. Integrate mental health and social determinant screening, as these often amplify environmental barriers.

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