Open Access Open Access  Restricted Access Subscription or Fee Access

Validity of a questionnaire for the detection of non-adherence in patients with complex medication regimens: a comparison with pill counts

Philipp Harbig, I Barat, E M Damsgaard


Objectives: The purpose of the study was to validate the ability of a questionnaire to detect non-adherence in elderly primary healthcare Danish patients with complex medication regimens. 

Methods: The tested questionnaire comprised the 4-item Morisky Medication Adherence Scale (MMAS-4) with 10 additional supplementary questions. Non-adherence rates in 577 elderly Danish patients were determined by the questionnaire and compared with non-adherence rates estimated by pill count (PC) using contingency table analysis. The stability of the questionnaire was evaluated by test-retest reliability correlation analyses comparing the non-adherence rates of 222 participants at three visits (0, 6 and 12 months).

Results: The MMAS-4 overestimated non-adherence (visit 2: 53%, visit 3: 55%) compared with the PC (visit 2: 15%, visit 3: 12%), as did the 14-item version of the questionnaire (visit 2: 29%, visit 3: 32%). Compared with the reference standard, the estimated sensitivity to detect non-adherence by the MMAS-4 at visit 2 was 47.9 (95% CI: 43.4-52.4); visit 3: 45.7 (41.3-50.1) and the specificity visit 2: 60.5 (49.3-70.8); visit 3: 61.2 (48.5-72.9). The sensitivity of the 14-item version was visit 2: 72.7 (68.5-76.6); visit 3: 68.8 (64.6-72.8) and the specificity visit 2: 39.5 (29.2-50.7); visit 3: 37.3 (25.8-50.0).

Conclusion: MMAS-4 and MMAS-4 with 10 additional questions over-estimated non-adherence and did not appear valid for detection of non-adherence in elderly home living patients with complex medication regimens. The questionnaire may be a useful tool for preliminary detection of non-adherent patients as part of person-centered care, but cannot be recommended for screening of non-adherent drug intake.


Adherence, complex medication regimens, compliance, drug, elderly, interview, medication, Morisky Scale, person-centered medicine, pill count, questionnaire

Full Text:



Vik, S.A., Maxwell, C.J. & Hogan, D.B. (2004). Measurement, correlates, and health outcomes of medication adherence among seniors. Annals of Pharmacotherapy 38 (2) 303-312.

Voils, C.I., Hoyle, R.H., Thorpe, C.T., Maciejewski, M.L. & Yancy, W.S., Jr. (2011). Improving the measurement of self-reported medication nonadherence. Journal of Clinical Epidemiology 64 (3) 250-254.

Morisky, D.E. & DiMatteo, M.R. (2011). Improving the measurement of self-reported medication nonadherence: response to authors. Journal of Clinical Epidemiology 64 (3) 255-257.

Wagner, G.J. (2002). Predictors of antiretroviral adherence as measured by self-report, electronic monitoring, and medication diaries. AIDS Patient Care and STDs 16 (12) 599-608.

Kimmerling, M., Wagner, G. & Ghosh-Dastidar, B. (2003). Factors associated with accurate self-reported adherence to HIV antiretrovirals. International Journal of STDs and AIDS 14 (4) 281-284.

Morisky, D.E., Green, L.W. & Levine, D.M. (1986). Concurrent and predictive validity of a self-reported measure of medication adherence. Medical Care 24 (1) 67-74.

Kalichman, S.C., Amaral, C.M., Cherry, C., Flanagan, J., Pope, H., Eaton, L., Kalichman, M.O., Cain, D., Detorio, M., Caliendo, A. & Schinazi, R.F. (2008). Monitoring medication adherence by unannounced pill counts conducted by telephone: reliability and criterion-related validity. HIV Clinical Trials 9 (5) 298-308.

Harbig, P. (2011). Methods for Improving Compliance with Medicine Intake (MICMI). Available at: (last accessed: 23. February 2012).

de Klerk, E., van der Heijde, D., Landewe, R., van der Tempel, H. & van der Linden, S. (2003). The compliance-questionnaire-rheumatology compared with electronic medication event monitoring: a validation study. Journal of Rheumatology 30 (11) 2469-2475.

Schoberberger, R., Janda, M., Pescosta, W. & Sonneck, G. (2002). The COMpliance Praxis Survey (COMPASS): a multidimensional instrument to monitor compliance for patients on antihypertensive medication. Journal of Human Hypertension 16 (11) 779-787.

Harbig, P., Barat, I., Lund Nielsen, P. & Damsgaard, E.M. (2012). Instantaneous detection of nonadherence: quality, strength, and weakness of an electronic prescription database. Pharmacoepidemiology and Drug Safety 21 (3) 323-328.

Kalichman, S.C., Amaral, C.M., Swetzes, C., Jones, M., Macy, R., Kalichman, M.O. & Cherry, C. (2009). A simple single-item rating scale to measure medication adherence: further evidence for convergent validity. Journal of the International Association of Physicians in AIDS Care8 (6) 367-374.

Garfield, S., Clifford, S., Eliasson, L., Barber, N. & Willson, A. (2011). Suitability of measures of self-reported medication adherence for routine clinical use: a systematic review. BMC Medical Research Methodology 11, 149.

Morris, A.B., Li, J., Kroenke, K., Bruner-England, T.E., Young, J.M. & Murray, M.D. (2006). Factors associated with drug adherence and blood pressure control in patients with hypertension. Pharmacotherapy 26 (4) 483-492.

Krousel-Wood, M., Joyce, C., Holt, E., Muntner, P., Webber, L.S., Morisky, D.E., Frohlich, E.D. & Re, R.N. (2011). Predictors of decline in medication adherence: results from the cohort study of medication adherence among older adults. Hypertension 58 (5) 804-810.

Miles, A. & Mezzich, J.E. (2011). The care of the patient and the soul of the clinic: person-centered medicine as an emergent model of modern clinical practice. International Journal of Person Centered Medicine 1 (2) 207-222.



  • There are currently no refbacks.