1. Introduction


This End-User License Agreement (EULA) is a legal agreement between the user ("Licensee") and MMAR, LLC ("Licensor") of the Morisky Medication Adherence Scale (MMAS). By using the MMAS for research and publication, the Licensee agrees to be bound by the terms and conditions of this EULA.


2. Grant of License


The Licensor grants the Licensee a non-exclusive, non-transferable, limited license to use the MMAS for the purposes of research and publication as specified herein. This license is granted on the condition that the Licensee adheres to all terms and conditions set forth in this EULA.


3. Use Restrictions


The Licensee agrees to use the MMAS solely for academic, clinical, or research purposes. The Licensee shall not:
- Distribute, sublicense, lease, sell, or otherwise transfer the MMAS to any third party.
- Reverse engineer, decompile, or disassemble the MMAS.
- Publish, disclose, or share the MMAS scoring algorithm, which remains a protected trade secret of the Licensor.


4. Confidentiality


The Licensee acknowledges that the MMAS scoring algorithm is confidential and proprietary information. The Licensee agrees to:
- Maintain the confidentiality of the scoring algorithm.
- Take all reasonable measures to protect the confidentiality of the scoring algorithm.
- Not disclose the scoring algorithm to any third party without the prior written consent of the Licensor.


5. Data Reporting and Publication


The Licensee may use the MMAS in research and publications under the following conditions:
- Proper attribution must be given to the Licensor in any research reports, articles, or publications that include data derived from the MMAS.

The MMAS-8 Scale, content, name, and trademarks are protected by US copyright and trademark laws. Permission for use of the scale and its coding is required. A license agreement is available from MMAR, LLC., Donald E. Morisky, ScD, ScM, MSPH; [email protected].

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- The Licensee must provide the Licensor with a copy of any published research that includes data derived from the MMAS.
- The Licensee may not disclose the detailed scoring algorithm in any publication or presentation.
- The scoring must be posted as follows:


The MMAS-8 scale consists of 8 items. Each of the first 7 items has 2 possible responses (yes/no), while the 8th item is answered with a 5-point Likert scale. The possible total medication adherence score ranges between 0 and 8, and the higher the score, the better the adherence level. A total score < 6 is considered low adherence, while a total score of ≥ 6 but < 8 indicates moderate adherence, and a score of 8 indicates high adherence.


6. Ownership


The MMAS and all associated intellectual property rights remain the sole property of the Licensor. This EULA does not grant the Licensee any ownership rights in the MMAS or its scoring algorithm.


7. Termination


This license is effective until terminated. The Licensor may terminate this license at any time if the Licensee breaches any of the terms and conditions of this EULA. Upon termination, the Licensee must cease all use of the MMAS and destroy all copies of the MMAS in their possession.


8. Limitation of Liability


The MMAS is provided "as is" without any warranties, express or implied. The Licensor shall not be liable for any damages arising out of or in connection with the use or performance of the MMAS.


9. Governing Law


This EULA shall be governed by and construed in accordance with the laws of the state of California, without regard to its conflict of laws principles.


10. Entire Agreement


This EULA constitutes the entire agreement between the Licensee and the Licensor with respect to the use of the MMAS and supersedes all prior or contemporaneous understandings regarding such subject matter.


11. Amendments


The Licensor reserves the right to amend the terms of this EULA at any time. Any amendments will be effective upon notice to the Licensee.


By using the MMAS, you acknowledge that you have read, understood, and agree to be bound by the terms and conditions of this EULA.

Professor Donald Morisky in the Department of Community Health Sciences at the UCLA Fielding School of Public Health, received the Distinguished Career Award from the Public Health Education and Health Promotion section of the American Public Health Association. The award is given for outstanding contribution to the practice and profession of health education, health promotion and/or health communications.

Morisky directs the School of Public Health's doctoral training program in the social and behavioral determinants of HIV/AIDS, and served as vice-chair of his department from 1994-2003 and chair from 2004-2005. He teaches core courses in program planning, survey research methods and evaluation. He also teaches courses on research methodology and courses on the social and behavioral determinants of HIV/AIDS prevention from a global perspective.
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Morisky's research is directed to both chronic and infectious diseases, specifically the risk factors for cardiovascular disease (high blood pressure, diabetes, smoking and elevated cholesterol), tuberculosis control and HIV/AIDS prevention. He has conducted research in the Philippines for over 30 years, and he is currently a co-investigator on an NIA research grant addressing medication-taking behavior among the elderly, in collaboration with the Oschner Clinic at Tulane University.

When using eDOT the major concern for the clinical trial is the lost opportunity of building rapport with the patient to determine if they are “intentionally” or “unintentionally” non-adherent. Some patients thrive on personal contact and the opportunity for tailored counseling.

​Intentional medication non-adherence is an active decision from the patient to take their medication as prescribed. This is a process in which a patient makes a rational decision based on the benefits of medication adherence compared to risks of medication non-adherence.

​Unintentional medication non-adherence is a passive process in which the patient does not adhere to how the medication is prescribed because they forget, don’t understand, or because of poor health literacy.

Most clinical trials use the Morisky Method as validated measures of medication adherence due to the affordability of administering the scale. Most clinical trials do not have the budget or resources for Directly observed therapy (DOT) to ensure patients take their medication as prescribed and complete their treatment. DOT involves observing drug administration in which a health care professional watches as a person takes each dose of a medication.

The MMAS-8 has undergone numerous levels of validation and has the closest type of validation which mimics the "gold standard", criterion-related validity. The self-reported MMAS-8 agreed with physiological outcome measures such as BP control, HgA1c levels, GFR rates, HDL/LDL ratios, viral load levels, topical skin disorders, etc.

Question #8 is related to polypharmacy and asks specifically, "how often do you have difficulty remembering to take all of your medications?" This is to identify problems remembering or forgetting as a whole, not just on a specific treatment plan. This has been validated with an Internal Consistency
Cronbach's alpha .83, Sensitivity 93%, and Specificity 57%. For example, a patient might remember to take all of their oral anticoagulation medications, but if they have high blood pressure as well. There is no medication that substantially does both.

A HUGE ADVANTAGE for using the Morisky Scales is the ability to tailor the health condition and medication(s) with MAPI validated translations.

​Additionally, global translations must ensure that what we are asking is actually what is intended to be asked, we partner with an ISO17100:2015 services provider to translate customized questions using medical conditions and complex medication names.

Did the clinical trial use the Morisky? The Morisky Medication Adherence Scale is a simple and effective tool to address medication non-adherence in clinical trials. With an Internal Consistency
Cronbach's alpha .83, Sensitivity 93%, and Specificity 57%. It has been validated by clinicians and health professionals for different chronic conditions. It has been translated in over 90 languages. It can be administered electronically or at each office visit for long-term consistent evaluation.

The MMAS-8 has undergone numerous levels of validation, including construct validation, discriminant validation, convergent validity with the MMAS scales, and the closest type of validation which mimics the "gold standard", criterion-related validity. The self-reported MMAS-8 agreed with physiological outcome measures such as BP control, HgA1c levels, GFR rates, HDL/LDL ratios, viral load levels, topical skin disorders, etc.

This question addresses unintentional medication non-adherence. Unintentional medication non-adherence is a passive process in which the patient does not adhere to how the medication is prescribed because of several domains of non-adherence such as they forget, don’t understand, or because of poor health literacy.

As a healthcare provider you can tailor your counseling when you understand why the patient is forgetting to take their medication. The MMAS-8 scale is not only used for measuring the magnitude of non-adherence but also provides a diagnostic assessment as to why the patient is non-adherent so health care providers can tailor educational counseling sessions and motivational interviewing questions to improve their medication taking behavior.
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The reason why the Morisky scales are highly validated is because of the way the questions are phrased to avoid “yes saying” bias. The MMAS-8 was conceptualized to reduce victim blaming by reversing the direction of the question. The MMAS-8 never asks the patient "Do you always take your high blood pressure medication" because 90% of my patients will say "yes, doctor" because they don’t want to be blamed for not taking their medication. So, we ask in the negative direction, "Do you sometimes forget to take your high blood pressure medication"? Now about 50% will respond "yes".