Activating patients to improve adherence

  • The Patient Activation Measure (PAM) and Medication Adherence Questionnaire (MAQ) are tools providers can use to measure patients’ health behavior
  • The PAM can be used to evaluate a patient’s ability to manage their health and conditions; the Medication Adherence Questionnaire can be used to evaluate the patient’s level of adherence to their prescribed therapies
  • These tools can be used by providers to characterize patients’ needs and follow up with targeted information and intervention support

Validated survey tools are useful for characterizing patient health behavior

As we have seen in other articles, chronic diseases are a global public health issue, increasing in prevalence and associated costs. Patients’ self-management behavior, including adherence to therapeutic recommendations, is the greatest single determinant of their prognosis.1 

Vertigo is a symptom of peripheral or central vestibular disorders, and 10% of the population will struggle with it during their lifetime.2 Treatment includes medication and self-management, including psychosocial adjustments. While information on adherence patterns for vestibular disorders is limited, epilepsy adherence patterns may be informative. Adherence to epilepsy medication is associated with improved control of symptoms; however, non-adherence rates are significant and associated with poorer outcomes.3

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.4 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.5 

Emotionally supportive providers who seek to empower patients to take control of their disease self-management have higher levels of patient activation and better adherence outcomes.

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 series.6

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, 6 

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.6

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.7 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.4, 5, 7

  • The Medication Adherence Questionnaire (MAQ), also known as the 4-item Morisky Medication Adherence Scale (MMAS-4) or the Morisky Scale,7 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.4 Questions for patients with vertigo would include:
    • Do you sometimes forget to take your medication?
    • When you feel like your vertigo symptoms are 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 vestibular disease patients would include:
    • How many vestibular disease medications do you take?
    • List all current vestibular disease medications.4

While each has its unique strengths and weaknesses, all 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 vertigo.5 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 vertigo:

  • Stage 1. Disengaged and Overwhelmed: The patient does not strongly believe in or understand his role in managing his care. The patient may not seek information about his condition or take medication as prescribed because he does not see himself as responsible for managing his symptoms.
  • 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 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.8, 9

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 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 symptoms are under control, do you sometimes stop taking your medications?4

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 vertigo symptoms may lack elementary knowledge about vestibular diseases 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.8 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. Rebecca L. Kinney et al. (2015). “The association between patient activation and medication adherence, hospitalization, and emergency room utilization in patients with chronic illnesses: A systematic review,” Patient Education and Counseling, (98):5, pp. 545–552.
  2. Eva Kovacs et al. (2019). “Economic burden of vertigo: A systematic review,” Health Economics Review, (9):1 p. 37. https://doi:10.1186/s13561-019-0258-2
  3. James W. McAuley et al. (2008). “An evaluation of self-management behaviors and medication adherence in patients with epilepsy,” Epilepsy & Behavior, (13):4, pp. 637–641.
  4. Josip Culig & Marcel Leppee (2014). “From Morisky to Hill-Bone; self-reports scales for measuring adherence to medication,” Collegium Antropologicum, (38):1, pp. 55–62.
  5. Stacey M. Lavsa, Ashley Holzworth, & Nicole T. Ansani (2011). “Selection of a validated scale for measuring medication adherence,” Journal of the American Pharmacists Association, (51):1, pp. 90–94.
  6. Guendalina Graffigna, Serena Barello, & Andrea Bonanomi (2017). “The role of Patient Health Engagement Model (PHE-model) in affecting patient activation and medication adherence: A structural equation model,” PloS One, (12):6. https://doi: 10.1371/journal.pone.0179865
  7. Wai Yin Lam & Paula Fresco (2015). “Medication adherence measures: An overview,” BioMed Research International, Epub.
  8. Judith H. Hibbard et al. (2004). “Development of the Patient Activation Measure (PAM): Conceptualizing and measuring activation in patients and consumers,” Health Services Research, (39):4, Pt. 1, pp. 1005 –26. https://doi:10.1111/j.1475-6773.2004.00269.x
  9. Ronald Gimbel et al. (2017). “Enhancing mHealth technology in the patient-centered medical home environment to activate patients with Type 2 diabetes: A multisite feasibility study protocol,” JMIR Research Protocols, (6):3, e38.
  10. Michael Weiser et al. (1998). “Homeopathic vs conventional treatment of vertigo,” JAMA Archives of Otolaryngology–Head & Neck Surgery, (124):8, p. 879. doi:10.1001/archotol.124.8.879