Step-by-Step Guide for Pharmacists Using MMAS-4 and MMAS-8

Screening Tools used

1. MMAS-4 (Morisky Medication Adherence Scale – 4 items): This is a quick screening tool to assess medication adherence.
2. MMAS-8 (Morisky Medication Adherence Scale – 8 items): A more detailed tool for patients who score low on the MMAS-4, to further evaluate their adherence behaviors into intentional or un-intentional domains.
3. WHO Dimensions of Adherence: According to the World Health Organization, five key factors influence medication adherence: social/economic factors, healthcare system factors, condition-related factors, therapy-related factors, and patient-related factors.

Step 1: Administer the MMAS-4 to Screen for Adherence

1. Introduce the MMAS-4:
​Explain to the patient that you will ask a few questions to assess how well they are following their prescribed medication regimen. Emphasize that there are no right or wrong answers.

2. Ask the MMAS-4 Questions:

1. Do you ever forget to take your medication?
2. Do you ever have problems remembering to take your medication?
3. When you feel better, do you sometimes stop taking your medication?
4. Sometimes if you feel worse when you take your medication, do you stop taking it?

3. Score the MMAS-4:
• 4 = High adherence
• 2-3= Medium adherence
• 0-1 = Low adherence
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4. Interpret the Results:
• High adherence (4): No further action is needed.
• Medium adherence (2-3): Use clinical judgment to decide if further screening is necessary.
• Low adherence (0-1): Administer the MMAS-8 for a more in-depth assessment.

Step 2: Administer the MMAS-8 for Low Adherence Patients

1. Explain the Purpose:
If the patient scores low on the MMAS-4, let them know that you will ask a few more detailed questions to understand their medication-taking behavior better.

2. Ask the MMAS-8 Questions:

1. Do you sometimes forget to take your medication?
2. People sometimes forget to take their medications for reasons other than forgetting. Thinking over the past two weeks, were there any days when you did not take your medication?
3. Have you ever cut back or stopped taking your medication without telling your doctor, because you felt worse when you took it?
4. When you travel or leave home, do you sometimes forget to bring your medication?
5. Did you take your medication the last time you were supposed to take it?
6. When you feel like your symptoms are under control, do you sometimes stop taking your medication?
7. Taking medication every day is a real inconvenience for some people. Do you ever feel hassled about sticking to your treatment plan?
8. How often do you have difficulty remembering to take all your medications?

3. Score the MMAS-8:

• High adherence: Score of 8
• Medium adherence: Score of 6-<8
• Low adherence: Score of <6

Identify Intentional vs. Unintentional Non-Adherence

Step 3: Identify WHO Dimensions of Adherence

WHO outlines 5 key dimensions that influence medication adherence:

1. Social/Economic Factors:

• Includes cost of medications, access to healthcare, social support, and health literacy.
• Pharmacist Role: Discuss financial barriers, access to insurance, and available social support systems.

2. Healthcare System/Team Factors:

• Poor provider-patient communication, lack of follow-up, and poor healthcare infrastructure can affect adherence.
• Pharmacist Role: Encourage communication with healthcare providers and help patients navigate the healthcare system.

3. Condition-Related Factors:

• Chronic diseases, complexity of condition, and asymptomatic diseases (e.g., hypertension) can lead to poor adherence.
• Pharmacist Role: Educate patients about their condition, even if symptoms aren’t visible, to emphasize the importance of ongoing treatment.

4. Therapy-Related Factors:

• Side effects, complexity of the medication regimen, and duration of therapy can impact adherence.
• Pharmacist Role: Assess and address concerns related to side effects, simplify medication regimens when possible.

5. Patient-Related Factors:

• Beliefs about medication, motivation, mental health, and health literacy all contribute to adherence behavior.
• Pharmacist Role: Engage with patients about their beliefs, motivations, and concerns, and provide education tailored to their health literacy level.

Step 4: Develop a Medication Adherence Action Plan (MAAP)

1. Morisky Score

• MMAS-8 score

2. WHO Dimension

• WHO dimension

3. Actions for Patient and Healthcare Provider

• Goals are Specific, Measurable, Achievable, Relevant, and Time-bound.

4. Leverage Technology:

• Introduce the use of mobile apps, pill organizers, and automatic refill services as tools to help with unintentional non-adherence.

5. Follow Up:

• Regularly monitor and reassess the patient’s progress. Set up follow-up appointments or calls to track improvement and adjust the MAAP as needed.

By utilizing the MMAS-4 and MMAS-8 effectively and considering the WHO dimensions of adherence, pharmacists can create a patient-centered plan to significantly improve medication adherence.
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