Using the MMAS-8 and Validated Scales to Assess Medication Adherence and WHO Barriers

Medication non-adherence is a pervasive challenge in healthcare, contributing to poor health outcomes, increased hospitalizations, and rising costs. The World Health Organization (WHO) identifies five dimensions of barriers to adherence: patient-related, condition-related, therapy-related, health system/healthcare team-related, and social/economic factors. To effectively address non-adherence, clinicians and researchers must first identify whether a patient is non-adherent and whether their non-adherence is intentional (deliberate) or unintentional (e.g., due to forgetfulness). The Morisky Medication Adherence Scale (MMAS-8) is a widely used, validated tool to assess adherence and distinguish between intentional and unintentional non-adherence. By combining MMAS-8 with other validated scales, healthcare providers can pinpoint specific WHO barriers and tailor interventions accordingly. This blog explores how to use the MMAS-8 to assess adherence and leverage complementary scales to identify WHO barriers.
Step 1: Assessing Adherence with the MMAS-8
The MMAS-8 is an 8-item, self-report questionnaire designed to measure medication adherence, particularly for chronic conditions like hypertension, diabetes, or asthma. It is simple to administer, takes about 2–3 minutes, and is validated across diverse populations. The scale includes questions that assess both unintentional and intentional non-adherence, making it an ideal starting point.
How the MMAS-8 Works
• Structure: Seven yes/no questions and one 5-point Likert scale question.
• Scoring: Each item is scored (0 or 1 for yes/no; 0–1 for the Likert scale). Total scores range from 0 to 8:
• High adherence: Score = 8
• Medium adherence: Score = 6 - <8
• Low adherence: Score < 6
• Distinguishing Intentional vs. Unintentional Non-Adherence:
• Unintentional: Items like “Do you sometimes forget to take your pills?” or “Did you not take any of your medicine over the past weekend?” reflect forgetfulness or carelessness.
• Intentional: Items like “Have you ever cut back or stopped taking your medication without telling your doctor because you felt worse?” or “When you feel like it’s not working, do you stop taking it?” indicate deliberate choices.
Using MMAS-8 in Practice
Imagine a patient with type 2 diabetes who scores 4 on the MMAS-8, indicating low adherence. Their responses show they often forget to take their medication (unintentional) but also stop taking it when they feel better (intentional). This dual insight guides the next steps: addressing forgetfulness (e.g., reminders) and exploring reasons for intentional non-adherence (e.g., beliefs or side effects).

​Step 2: Mapping WHO Barriers with Validated Scales Once non-adherence is identified and classified as intentional or unintentional, clinicians can use targeted scales to explore the underlying WHO barriers. Below, we outline each dimension, corresponding scales, and how they complement MMAS-8 findings.
1. Patient-Related Factors
These include knowledge, beliefs, motivation, or psychological factors. Intentional non-adherence often stems from negative beliefs or low motivation, while unintentional non-adherence may relate to cognitive issues.
• Validated Scale: Beliefs about Medicines Questionnaire (BMQ)
• Purpose: Measures beliefs about medication necessity and concerns about side effects.
• How It Helps: If the MMAS-8 indicates intentional non-adherence (e.g., stopping medication due to feeling worse), the BMQ can reveal if this is due to concerns about side effects or low perceived necessity. For example, a patient who believes their diabetes medication is harmful may score high on BMQ-Concerns, guiding interventions like patient education.
• Example: A patient with a high BMQ-Concerns score might benefit from counseling to address misconceptions about medication risks.
• Alternative Scale: Medication Adherence Self-Efficacy Scale (MASES)
• Purpose: Assesses confidence in adhering to medication regimens.
• How It Helps: For unintentional non-adherence (e.g., forgetting doses), low MASES scores may indicate low self-efficacy, suggesting interventions like adherence aids or skill-building.
2. Condition-Related Factors
The nature of the disease (e.g., asymptomatic conditions, chronicity) can affect adherence. For example, patients with asymptomatic hypertension may intentionally skip doses due to a lack of perceived need.
• Validated Scale: Patient Activation Measure (PAM)
• Purpose: Assesses patients’ knowledge, skills, and confidence in managing their condition.
• How It Helps: A low PAM score in a patient with low MMAS-8 adherence may indicate poor understanding of their condition’s severity, contributing to intentional non-adherence. For instance, a hypertensive patient may not see the need for daily medication if they feel fine.
• Example: A low PAM score could prompt disease-specific education to improve condition awareness and adherence.
• Alternative: Disease-specific scales (e.g., Asthma Control Test for asthma) can assess how symptom burden or disease control affects adherence.
3. Therapy-Related Factors
Complex regimens, side effects, or long treatment duration can lead to both intentional (e.g., stopping due to side effects) and unintentional (e.g., missing doses due to complexity) non-adherence.
• Validated Scale: Treatment Satisfaction Questionnaire for Medication (TSQM)
• Purpose: Measures satisfaction with medication, including side effects, convenience, and effectiveness.
• How It Helps: If MMAS-8 shows intentional non-adherence, a low TSQM score for side effects or convenience may explain why. For example, a patient stopping their medication due to gastrointestinal side effects might score low on TSQM-Side Effects.
• Example: Simplifying the regimen or switching medications could address low TSQM scores and improve adherence.
• Alternative: Adherence to Refills and Medications Scale (ARMS) can further explore regimen complexity or refill issues.
4. Health System/Healthcare Team-Related Factors
Poor provider communication, limited access to care, or lack of trust can hinder adherence. These may contribute to intentional non-adherence (e.g., distrust in provider advice) or unintentional (e.g., inability to access refills).
• Validated Scale: Health Care Climate Questionnaire (HCCQ)
• Purpose: Assesses patient perceptions of provider support and communication.
• How It Helps: If MMAS-8 indicates low adherence, a low HCCQ score may suggest poor provider-patient relationships, prompting interventions like shared decision-making or improved communication.
• Example: A patient with a low HCCQ score might benefit from regular follow-ups with a trusted provider to build rapport.
• Alternative: Primary Care Assessment Survey (PCAS) evaluates access and continuity of care, which can uncover system-level barriers.
5. Social and Economic Factors
Cost, social support, health literacy, or cultural beliefs can drive non-adherence. For example, financial barriers may lead to intentional dose-skipping, while low social support may cause unintentional lapses.
• Validated Scale: Social Support Survey (SSS)
• Purpose: Measures perceived social support for health behaviors.
• How It Helps: A patient with unintentional non-adherence on MMAS-8 and low SSS scores may lack support for medication routines, suggesting interventions like involving family or community resources.
• Example: Connecting a patient with a support group could improve adherence if SSS scores are low.
• Alternative: Medication Access and Adherence Tool (MAAT) assesses cost-related barriers, particularly in low-resource settings.

​Step 3: Integrating Findings for Tailored Interventions with the MAAP In the blog’s Step 3, we discussed integrating findings from the Morisky Medication Adherence Scale (MMAS-8) with validated scales to map barriers to medication adherence across the five WHO dimensions and design tailored interventions. Here, we expand on this by incorporating the Medication Adherence Assessment Protocol (MAAP), a structured approach that can complement the MMAS-8 and other scales to systematically address adherence barriers, particularly for the social and economic dimension, but also applicable across all dimensions. The MAAP, while not as commonly referenced as scales like the BMQ or TSQM, is a framework used in some clinical and research settings to assess and address adherence barriers comprehensively. Below, we discuss how the MAAP can be integrated into Step 3 to enhance the intervention process.
What is the MAAP?
The Medication Adherence Assessment Protocol (MAAP) is a structured, multi-step process designed to assess medication adherence, identify barriers, and guide interventions. It typically involves:
• Assessment: Using standardized tools (like MMAS-8) to measure adherence and classify it as intentional or unintentional.
• Barrier Identification: Pinpointing specific barriers across the WHO dimensions through patient interviews, questionnaires, or validated scales.
• Intervention Planning: Developing tailored strategies based on identified barriers, often involving interdisciplinary collaboration.
• Follow-Up: Monitoring adherence over time to evaluate intervention effectiveness.
The MAAP is flexible and can incorporate various validated scales, making it ideal for integrating MMAS-8 findings with tools like the Beliefs about Medicines Questionnaire (BMQ), Patient Activation Measure (PAM), Treatment Satisfaction Questionnaire for Medication (TSQM), Health Care Climate Questionnaire (HCCQ), and Social Support Survey (SSS). It emphasizes patient-centered care and iterative refinement of interventions.