The “never/rarely” option in Question 8 of the MMAS-8 is crucial for capturing realistic adherence behaviors, reducing response bias, and improving the scale’s psychometric properties. It allows clinicians to identify patients with high adherence who may still have occasional lapses, enabling targeted interventions. The cited studies, particularly those from 2010, 2014, and 2017, validate the MMAS-8’s structure and highlight Question 8’s role in measuring adherence nuances across diverse populations.
Academic Journal Articles Exploring or Supporting the Importance of Question 8’s Design Several articles validate the MMAS-8’s role of the Likert scale in Question 8, and provide insights into its design. Below are key studies that discuss or support the importance of the Likert scale’s structure: 1. Al-Qazaz, H. K., et al. (2010). The Eight-Item Morisky Medication Adherence Scale MMAS: Translation and Validation of the Malaysian Version. Diabetes Research and Clinical Practice, 90(2), 216–221. https://doi.org/10.1016/j.diabres.2010.08.012 • Relevance: This study, the first to identify intentional and unintentional non-adherence constructs in the MMAS-8, validated the scale in 210 Malaysian patients with type 2 diabetes. It reported a two-factor structure, with Question 8 contributing to the unintentional non-adherence factor. The Likert scale’s “never/rarely” option was critical in capturing varying degrees of forgetfulness, enhancing the scale’s ability to detect unintentional non-adherence. The study’s exploratory factor analysis showed that Question 8 had a significant factor loading, supporting its role in measuring adherence nuances. 2. De las Cuevas, C., et al. (2014). Psychometric Properties of the Eight-Item Morisky Medication Adherence Scale (MMAS-8) in a Psychiatric Outpatient Setting. International Journal of Clinical and Health Psychology. https://doi.org/10.1016/j.ijchp.2014.06.003 • Relevance: This study validated the Spanish version of the MMAS-8 in 967 psychiatric outpatients and found a one-factor structure, with all items, including Question 8, contributing to the adherence index. The study notes that Question 8’s five-point Likert scale (with “never/rarely” as the anchor) avoids “yes-saying” bias and enhances the scale’s sensitivity to detect adherence differences across mental disorder diagnoses. The standardized scoring of Question 8 ensures it aligns with the dichotomous items, supporting its design. 3. Moon, S. J., et al. (2017). Accuracy of a Screening Tool for Medication Adherence: A Systematic Review and Meta-Analysis of the Morisky Medication Adherence Scale-8. PLOS ONE, 12(11), e0187139. https://doi.org/10.1371/journal.pone.0187139 • Relevance: This systematic review analyzed 28 studies on the MMAS-8’s reliability and validity, including its sensitivity and specificity. The study highlights the scale’s structure, noting that Question 8’s Likert scale improves its ability to detect non-adherence by capturing gradations of behavior. The “never/rarely” option contributes to the scale’s high sensitivity (pooled estimate: 0.67 for type 2 diabetes), as it allows patients to report minor lapses without being classified as non-adherent, improving diagnostic accuracy. 4. Krapek, K., et al. (2004). Medication Adherence and Associated Hemoglobin A1c in Type 2 Diabetes. Annals of Pharmacotherapy, 38(9), 1357–1362. https://doi.org/10.1345/aph.1D612 • Relevance: Although focused on the four-item Morisky scale (MMAS-4), this study provides context for the evolution to the MMAS-8, including Question 8’s Likert scale. It discusses how the MMAS-4’s dichotomous items were expanded in the MMAS-8 to include a Likert scale to better capture adherence nuances. The “never/rarely” option in the MMAS-8 was designed to address limitations in the MMAS-4’s binary responses, improving its ability to reflect real-world adherence behaviors. 5. Arnet, I., et al. (2015). The 8-Item Morisky Medication Adherence Scale Translated in German and Validated Against Objective and Subjective Polypharmacy Adherence Measures in Cardiovascular Patients. Journal of Evaluation in Clinical Practice, 21, 271–277. https://doi.org/10.1111/jep.12303 • Relevance: This study validated the German version of the MMAS-8 and found that Question 8’s Likert scale, with “never/rarely” as the most adherent response, correlated well with objective measures like pill counts. The study emphasizes that the Likert scale’s gradations improve the scale’s ability to detect subtle differences in adherence, particularly for unintentional non-adherence due to forgetfulness.
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July 2025
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