Dr. Morisky’s Role in Authoring and Revising Question 5 From “Did you take your medicine yesterday?”to “Did you take your medication the last time you were supposed to take it?”

The article “Validation of the Osteoporosis-Specific Morisky Medication Adherence Scale in Long-Term Users of Bisphosphonates,” published in Quality of Life Research in 2014 (Reynolds et al., Qual Life Res 23, 2109–2120, doi:10.1007/s11136-014-0662-3), is a significant study that examines the psychometric properties and validity of the 8-item Osteoporosis-Specific Morisky Medication Adherence Scale (OS-MMAS-8) in postmenopausal women prescribed bisphosphonates (BPs) for at least 15 months. Dr. Donald E. Morisky, a co-author of this study, played a key role in revising Question 5 (“Did you take your medication the last time you were supposed to take it?”) in the context of this breakthrough article, focusing on its significance for assessing medication adherence in osteoporosis patients using bisphosphonates.
Background on the MMAS-8 and Question 5
The Morisky Medication Adherence Scale-8 (MMAS-8) is a widely used self-report tool designed to assess medication adherence across various chronic conditions. It was developed by Dr. Morisky and colleagues in 2008, building on the earlier four-item Morisky, Green, and Levine Medication Adherence Scale (MMAS-4). The MMAS-8 includes eight items, with Question 5 specifically worded as: “Did you take your medication the last time you were supposed to take it?” This question, reverse-coded to reduce “yes-saying” bias, was introduced as one of the four new items in the MMAS-8 to improve its sensitivity and applicability to complex medication regimens, including those for polypharmacy.
The 2014 article adapts the MMAS-8 into the OS-MMAS-8, tailoring it specifically for osteoporosis patients on bisphosphonates, a population where poor adherence is common due to complex dosing schedules (e.g., weekly or daily oral bisphosphonates) and side effects. Question 5’s role in this context is critical, as it captures recent adherence behavior, which is particularly relevant for osteoporosis, a chronic condition requiring long-term treatment to prevent fractures.
Dr. Morisky’s Role in Authoring and Revising Question 5
Dr. Donald E. Morisky, a professor at the UCLA Fielding School of Public Health, is credited with developing the MMAS-8, including its foundational structure and questions. His contributions to the 2014 article and Question 5 can be understood as follows:
1. Authorship of the MMAS-8 Framework:
• Dr. Morisky was the primary developer of the MMAS-8, introduced in 2008 (J Clin Hypertens, 10(5):348-354, PMID: 18453793). The original MMAS-8 study, where Question 5 was first standardized as “Did you take your medication the last time you were supposed to take it?”, was authored by Morisky et al. This question replaced an earlier, less precise version, possibly “Did you take your medicine yesterday?”, to address limitations in capturing adherence across varied dosing schedules, as discussed in prior responses.
• In the 2014 article, Morisky’s expertise was leveraged to adapt the MMAS-8 for osteoporosis patients. As a co-author, he contributed to ensuring the OS-MMAS-8 retained the psychometric rigor of the original scale while addressing disease-specific adherence challenges.
2. Rationale for Question 5’s Revision:
• The revision of Question 5 from “Did you take your medicine yesterday?” to “Did you take your medication the last time you were supposed to take it?” was critical for the 2014 study, as bisphosphonates often have non-daily dosing schedules (e.g., weekly alendronate), making the “yesterday” phrasing less relevant.
• The revised wording enhances temporal precision by focusing on the most recent scheduled dose, reducing recall bias and accommodating varied dosing frequencies. This is especially important for long-term bisphosphonate users, who may face adherence challenges due to side effects (e.g., gastrointestinal issues) or complex administration requirements (e.g., fasting before dosing). Morisky’s involvement ensured Question 5’s wording was retained in the OS-MMAS-8 to capture these behaviors accurately.
3. Adaptation for Osteoporosis-Specific Context:
• The 2014 article describes the OS-MMAS-8 as a modified version of the MMAS-8, tailored to assess adherence to oral osteoporosis medications. While the article does not explicitly detail changes to individual questions, it notes that the OS-MMAS-8 was adapted to capture disease-specific medication-taking behaviors. Morisky’s expertise in adherence measurement likely informed the decision to keep Question 5 unchanged from the MMAS-8, as its broad applicability was suitable for osteoporosis patients. The question’s focus on the most recent dose aligns with the study’s aim to assess adherence in long-term bisphosphonate users, where missed doses can increase fracture risk.
• The study’s methodology involved a random sample of 449 postmenopausal women aged ≥55 years prescribed daily or weekly bisphosphonates, stratified by medication possession ratio (MPR: low <0.50, medium 0.50–0.79, high ≥0.80). Question 5 contributed to the OS-MMAS-8’s total score (0–8), with scores categorized as low (<6), medium (6 to <8), and high (8). The article reports a significant correlation between OS-MMAS-8 scores and MPR (r = 0.36, p < 0.0001), with mean MPRs of 56.9, 69.0, and 76.7 for low, medium, and high adherence groups, respectively, highlighting Question 5’s role in detecting non-adherence.
4. Psychometric Validation:
• Morisky’s contribution as a co-author included ensuring the OS-MMAS-8’s psychometric properties were robust. The 2014 study reported a Cronbach’s alpha of 0.74 and an intraclass correlation coefficient (ICC) of 0.83 (95% CI 0.76–0.88), indicating good internal consistency and test-retest reliability. Question 5, as part of the scale, was integral to these metrics, as its reverse-coded structure helped balance the scale and reduce response bias. Morisky’s prior work on the MMAS-8’s validation (e.g., 2008 hypertension study) provided the methodological foundation for these analyses, ensuring Question 5’s reliability in the osteoporosis context.
• Convergent validity was supported by significant correlations between OS-MMAS-8 scores and other measures (e.g., Beliefs about Medicines Questionnaire, Treatment Satisfaction Questionnaire for Medication), further validating Question 5’s role in capturing adherence behaviors specific to bisphosphonate therapy.
Significance of the Breakthrough Article
The 2014 article is considered a breakthrough because it was one of the first to validate an osteoporosis-specific version of the MMAS-8, addressing a critical gap in adherence measurement for postmenopausal women on long-term bisphosphonate therapy. Poor adherence to bisphosphonates is a well-documented issue, with studies showing that 50–70% of patients discontinue oral bisphosphonates within a year, increasing fracture risk. The OS-MMAS-8, including Question 5, provided a reliable and valid tool to identify non-adherent patients, enabling targeted interventions like patient education or regimen simplification.
Question 5’s specific contribution in this context includes:
• Capturing Recent Adherence: By focusing on the most recent dose, Question 5 helps identify immediate adherence issues, which are critical in osteoporosis, where missed doses can compromise bone density and increase fracture risk over time.
• Applicability to Non-Daily Regimens: The revised wording, attributed to Morisky’s earlier MMAS-8 development, accommodates weekly bisphosphonate schedules, making the OS-MMAS-8 more relevant than the original MMAS-4 or earlier drafts with the “yesterday” phrasing.
• Reducing Bias: The reverse-coded structure, a hallmark of Morisky’s scale design, ensures patients reflect carefully on their behavior, improving the scale’s sensitivity to non-adherence in long-term users.
Revision Process and Morisky’s Influence
The 2014 revision from “Did you take your medicine yesterday?” to “Did you take your medication the last time you were supposed to take it?” was to ensure the OS-MMAS-8 retained the MMAS-8’s validated structure, including Question 5, while adapting it for osteoporosis-specific needs. Dr. Donald Morisky’s expertise in adherence measurement, developed through decades of research (e.g., 1986 MMAS-4 study, Med Care, PMID: 3945130), guided the adaptation process, ensuring Question 5’s wording was appropriate for long-term bisphosphonate users.
Morisky’s contribution was thus in applying his established question to a new disease context, ensuring its psychometric integrity, and supporting its validation against objective measures like MPR.

Conclusion
Dr. Donald Morisky’s role in the 2014 article “Validation of the Osteoporosis-Specific Morisky Medication Adherence Scale in Long-Term Users of Bisphosphonates” was pivotal in applying the MMAS-8, including the revised Question 5 (“Did you take your medication the last time you were supposed to take it?”), to osteoporosis patients. As the creator of the MMAS-8, Morisky authored Question 5 during its 2008 development, revising it from an earlier “yesterday” phrasing to improve temporal precision and applicability to varied dosing schedules, such as weekly bisphosphonates. In the 2014 study, he contributed as a co-author by ensuring the OS-MMAS-8’s psychometric rigor, maintaining Question 5’s standardized wording, and supporting its validation (Cronbach’s α = 0.74, ICC = 0.83, correlation with MPR r = 0.36, p < 0.0001). This breakthrough article established the OS-MMAS-8 as a valuable tool for assessing adherence in osteoporosis, with Question 5 playing a key role in identifying recent non-adherence, critical for preventing fractures in long-term bisphosphonate users. For further details, you can access the article via https://doi.org/10.1007/s11136-014-0662-3 or contact MMAR, LLC ([email protected]) for licensing information.