Activating patients to improve adherence

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Activating patients to improve adherence



Validated survey tools are useful for characterizing patient health behavior

As we have seen in other articles, chronic diseases, including cardiovascular diseases, are increasing in prevalence and associated costs. Patients’ self-management behavior, including adherence to other therapeutic recommendations, is the greatest single determinant of their prognosis.1 This raises the question of what exactly providers should target for best effect.

In the EU, 9% of cardiovascular disease (CVD) events may be attributable to poor adherence, and preventing unnecessary deaths is concrete objective. Approximately three-quarters of global CVD deaths occur in low- and middle-income countries, where socioeconomic barriers to adherence are significant and include high out-of-pocket costs and low medication availability. Treatment adherence is one of the most important determinants of the outcomes of CVD and other chronic conditions worldwide.2

Frameworks such as the Theory of Planned Behavior and the Behavioral Change Wheel can provide useful insight regarding patients’ health behaviors and suggest strategies to improve non-adherence and disease outcomes. They do not however address the question, What does adherent behavior look like?

A variety of validated quantitative measures have been developed for characterizing health behavior and supporting patients in the self-management of their conditions. Survey-based measures and questionnaires can be easily administered at the point of care and can provide important insight into patients’ behavior, beliefs, and barriers to adherence.3 Healthcare providers can use the information from these measures to provide targeted interventions and personalize patient care. The Patient Activation Measure (PAM), the Medication Adherence Questionnaire (MAQ), and the Brief Medication Questionnaire are all useful survey tools.4


The PAM reflects a patient’s ability to manage his health 

The PAM reflects “the individual’s knowledge, skill[,] and confidence in managing his/her own health and care,” and it is the most reliable indicator of a patient’s willingness and ability to autonomously manage his health and care. Activation theory is rooted in the Transtheoretical Behavioral Model discussed previously in this article series.5

The PAM-13 questionnaire categorizes the patient into one of four progressively higher “stages of activation.” Higher activation stages indicate that the patient is more engaged with healthy behaviors such as diet, exercise, and adherence to guidelines and treatments.1,5

Patient activation has been linked to positive clinical behavior and improved outcomes. There is significant interest in being able to evaluate and influence the patient’s activation stage. The importance of the healthcare provider/patient relationship and effective healthcare provider communication has been established: Emotionally supportive and easily accessible providers who recognize patient autonomy and motivate them to self-manage are associated with higher levels of patient activation.5

Medication questionnaires can efficiently quantify patient adherence

Scales and surveys specifically quantifying medication adherence include self-reported questionnaires. These questionnaires are practical, flexible, and can help healthcare providers to identify individual patient beliefs and concerns while providing real-time, relevant feedback to both patients and providers.6 While a number of adherence questionnaires are available, the Medication Adherence Questionnaire and the Brief Medication Questionnaire are consistently cited as validated exemplars in the literature.3,4,6

  • The Medication Adherence Questionnaire (MAQ), also known as the 4-item Morisky Medication Adherence Scale (MMAS-4) or the Morisky Scale,6 is the most common adherence scale. It is short, simple to use, and validated across many different disease areas. It addresses barriers to adherence but does not include a measure of self-efficacy.3 Questions for patients with hypertension would include:

        o    Do you sometimes forget to take your medication?
        o    When you feel like your hypertension is under control,
              do you sometimes stop taking your medicine?

  • The Brief Medication Questionnaire is similarly succinct and able to detect different types and drivers of non-adherence behavior, including regimen (repeat vs. sporadic), beliefs about drug efficacy, and recall (difficulties in remembering to take medication). Despite the name, the Brief Medication Questionnaire is more onerous to use at the point of care. Questions for hypertension patients would include:

        o    How many hypertension medications do you take?
        o    List all current hypertension medications.3

  • Finally, the Hill-Bone Compliance scale is useful to assess adherence specifically for high blood pressure medications and healthy behaviors for patients with cardiovascular disease.4 Questions include:

        o    How often do you decide not to take your medication?
        o    How often do you eat salty food?3

While each has its unique strengths and weaknesses, all three of these measures can be administered at the point of care, and they are relatively easy to administer, available in the English language, and are easily applicable to patients with hypertension.4 The results provide useful information for healthcare providers seeking to understand their patients’ adherence behavior and can inform routine clinical practice and non-adherence interventions.

Adherence measures can provide useful insight during routine clinical practice

PAM and medication adherence questionnaires can help healthcare providers understand their patients’ attitudes and beliefs about their health and adherence habits. Understanding where a patient is on the activation continuum can suggest the type of support or interventions that will be most helpful. PAM activation stages can be illustrated using the example of a typical patient with hypertension:

  • Stage 1. Disengaged and Overwhelmed: The patient does not strongly believe in or understand his role in managing his care. The patient may not reduce sodium in his diet or take medication regularly because he does not see himself as being responsible for managing his condition.
  • Stage 2. Aware but struggling: The patient feels responsible for managing his own care and adhering to treatment but may not take medication as directed because he does not fully understand the value of doing so or because he lacks the confidence needed to act.
  • Stage 3. Taking action: The patient is fully informed and autonomous, making needed lifestyle changes, and following through with his hypertension treatment as directed. He may, however, still need additional support to maintain his degree of adherence.
  • Stage 4. Maintaining and improving: The patient has been adhering to the prescribed regimen for some time but may not maintain the behavior under stress and may benefit from additional support.7, 8

During the patient’s regular check-up, his healthcare provider can use these measures to gain insight to improve adherence. Even without administering these specific tools, providers can make the following inquiries based on the PAM and medication adherence questionnaires:

  • How do you see your role with respect to your health? Do you think that taking an active role is important?
  • Do you know what lifestyle changes and treatments are available to you to improve your symptoms?
  • Do you know what your prescribed medications and therapies do?1 
  • When you feel like your hypertension is under control, do you sometimes stop taking your medicine?
  • How often do you eat salty food?3

Healthcare providers can use patients’ responses to tailor the support needed to boost patient activation and improve adherence. A patient who does not see himself as responsible for managing his hypertension may lack elementary knowledge about hypertension, cardiovascular disease and the possible outcomes. His provider can educate him regarding the condition and symptoms. Similarly, a patient with higher activation may have the necessary skills and knowledge to manage his condition and adhere to a treatment plan, but his adherence behavior may be derailed by stress or unexpected life or health events.7 Healthcare providers can positively influence activation and adherence by investigating and addressing patient questions or concerns and ensuring that patients know that support is available should any unexpected changes arise.

Theory-based interventions are available for healthcare providers and patients

Various behavioral models exist for understanding and influencing patients’ health behavior and treatment adherence. Surveys and questionnaires can complement more qualitative approaches. Healthcare providers can apply these tools, in whole or in part, to characterize patients’ needs and provide tailored support. Healthcare providers often have access to a variety of interventions and Patient Support Programs based on these theories and developed with input from healthcare experts specifically to assist with the management of chronic conditions. Patient Support Programs will be discussed in future articles in this series.


1. Kinney RL, Lemon SC, Person SD, Pagoto SL, Saczynski JS. The association between patient activation and medication adherence, hospitalization, and emergency room utilization in patients with chronic illnesses: A systematic review. Patient Educ Couns 2015;98(5):545–52.

2. Chowdhury R, Khan H, Heydon E, Shroufi A, Fahimi S, et al. Adherence to cardiovascular therapy: A meta-analysis of prevalence and clinical consequences. Eur Heart J 2013;34(38):2940-8.

3. Culig J, Leppee M. From Morisky to Hill-Bone; self-reports scales for measuring adherence to medication. Coll Antropol 2014;38(1):55-62.

4. Lavsa SM, Holzworth A, Ansani NT. Selection of a validated scale for measuring medication adherence. J Am Pharm Assoc 2011;51:90–94.

5. Graffigna G, Barello S, Bonanomi A. The role of Patient Health Engagement Model (PHE-model) in affecting patient activation and medication adherence: A structural equation model. PloS One 2017;12(6):1-19.

6. Lam WY, Fresco P. Medication adherence measures: An overview. Biomed Res Int 2015;2015:1-12.

7. Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res 2004;39(4):1005-26.

8. Gimbel R, Shi L, Williams JE, Dye CJ, Chen L, et al. Enhancing mHealth technology in the patient-centered medical home environment to activate patients with Type 2 diabetes: A multisite feasibility study protocol. JMIR Res Protoc 2017;6(3):e38.