1. Appointment-Keeping Behavior
​Patients who receive educational counseling 
2. Weight-Loss
3. Behavior Change 
4.  30-dauy Hospital Readmissions
5.  Morbidity and Mortality
6.  Quality of Life

​Social Desirability (SD) bias refers to the tendency of research subjects to give socially desirable responses instead of choosing responses that are reflective of their true feelings. The bias in responses due to this personality trait becomes a major issue when the scope of the study involves socially sensitive issues such as politics, personal issues such as drug use, cheating, smoking. and medication-taking. Whenever possible, it is desirable to measure the extent of the bias present in responses to a survey by incorporating a socially desirable scale in the survey. This is particularly a bias when we use indirect methods, such self-reported questionnaires.
The MMAS-8 was conceptualized to reduce the presence of SD by reversing the direction of the question. The MMAS-8 never asks the parient "Do you always take your high blood pressure medication" because 90% of my patients will say "yes, doctor". So, we ask in the negative direction, "Do you sometimes forget to take your high blood pressure medication"? Now about 50% will respond "yes".  

When a patient is adherent to their medications but their health condition is out of control this called a false positive.  A false positive gives the patient a dangerous illusion that they are in good health.  The first step to correcting false positives is to evaluate the dosing for the medications that the patient is taking.  Patients often receive new medications or have changes made to their existing medications.  Medication reconciliation is the process where medications prescribed by a health care provider are checked to ensure that they match and are current with their prescription. 

The Morisky Scales are unique because they don't treat non-adherence as a monolithic concept.  The Morisky Scales consist of two subscales, unintentional and intentional non-adherence, that are coded as four dichotomous (yes/no) variables in the MMAS-4 and seven dichotomous variables with a 5-point Likert scale in the MMAS-8.  The Morisky Protocol assesses the differential impact of unintentional (forgetfulness and polypharmacy) and intentional (stopping use of medication if feeling better or worse) medication non-adherence.  Using the Morisky Scale platform will score and recode your data with intentional and unintentional medication non-adherence.   The Morisky Protocol training will guide you through a process to tailor educational counceling focused on patient beneficence in the decision making about prescribed medicines.

The difference between the MMAS-4 and the MMAS-8 is that the MMAS-4 has very low reliability (Cronbach's alpha is only .68) compared to the .83 for the MMAS-8.  The MMAS-8 also has been able to identify many more long-term outcomes compared with the MMAS-4.  
Specifically, there are many more independent variables such as beliefs in medication-taking behavior as well as strong associations with knowledge of the medical regimen and positive attitudes regarding medication taking behavior.  Long-term outcomes include a very strong correlation of the MMAS-8 with the proportion in control of their health condition, reduction in 30-day appointment-keeping, quality of life, morbidity and mortality.  

Journal Articles regarding determinants of nonadherence 
Retrospective Cohort Study of Medication Adherence and Risk for 30-day Hospital Readmission in a Medicare Cost Plan
Barriers to Determinants of Medication Adherence in Hypertension Management: Perspective of Cohort Study of Medication Adherence Among Older Adults
Predictive Validity of a Medication Adherence Measure in an Outpatient Setting
​Effect of Intensive Blood-Pressure Treatment on Patient-Reported Outcomes

The consequence of not obtaining appropriate permission to use the 4-item or 8-item Morisky Scales will result in legal action and in some cases a retraction of published articles.  Unfortunately in recent years, there has been negative publicity in the use of my scales because of the aggressive and threatening demands from my former business partner.  I have reorganized and embarked on a management approach that utilizes best practices in dealing with clients, including those who have infringed on copyrights.  My focus is on maintaining the integrity of my copyright and encouringing scientific research.  If you have infringed on my copyrights please contact me for a retroactive license.   In most cases we can resolve the infringement through training on the Morisky Protocol.  

Where can I find other tools to increase the validity and reliability?

Morisky DE, Green LW, Levine DM. Concurrent and Predictive Validity of a Self-Reported Measure of Medication Adherence and Long-Term Predictive Validity of Blood Pressure Control.  Medical Care 1986

Morisky DE, Malotte CK, Choi P, et al. A Patient Education Program to Improve Adherence Rate with Anti-tuberculosis Drug Regimens.  Health Education Quarterly 1990; 17:253-286

Morisky DE, DiMatteo MR, Improving the measurement of self-reported medication non-adherence: Final response. J Clin Epidemio 2011; 64:258-263

Morisky DE, Ang A, Krousel-Wood M, Ward H. Predictive Validity of a Medication Adherence Measure for Hypertension Control. Journal of Clinical Hypertension 2008; 10(5):348-354

Berlowitz DR, Foy CG, Kazis LE, Bolin L, Conroy LB, Fitzpatrick P, Gure TR, Kimmel PL, Kirscner K, Morisky DE, Newman J, Okney C, Oparil S, et al. for the SPRINT Study Research Group. Impact of Intensive Blood Pressure Therapy on Patient-Reported Outcomes: Outcomes Results from the SPRINT Study. N Engl J Med. 2017;377:733-44.

​Bress AP, Bellows BK, King J, Hess  R, Beddhu S, Zhang Z, Berlowitz DR, Conroy MB, Fine L, Oparil S,  Morisky DE, Kazis LE, Ruiz-Negron N, Powell J, Tamariz L, Whittle J, et al, for the SPRINT Research Group and the SPRINT Economics and Health Related Quality of Life Subcommittee. Cost-Effectiveness of Intensive versus Standard Blood Pressure Control.  N Engl J Med 2017;377:745-55. DOI: 10.1056/NEJMsa1616035