Patient Education and Counseling 37 (1999) 113124

The brief medication questionnaire: A tool for screening patient

adherence and barriers to adherence
Bonnie L. Svarstad
a

1 ,a,

*, Betty A. Chewning2 ,a, Betsy L. Sleath2 ,b, Cecilia Claessonc

School of Pharmacy, University of Wisconsin-Madison, 425 No. Charter St., Madison, WI 53706, USA
b
Assistant Professor, College of Pharmacy, University of North Carolina at Chapel Hill, NC, USA
c
Swedish National Board of Health and Welfare, Stockholm, Sweden
Received 3 March 1998; received in revised form 30 April 1998; accepted 16 July 1998

Abstract
Self-report tools for monitoring adherence can be useful in identifying patients who need assistance with their
medications, assessing patient concerns, and evaluating new programs. The aim of this study is to test the validity of the
Brief Medication Questionnaire (BMQ), a new self-report tool for screening adherence and barriers to adherence. The tool
includes a 5-item Regimen Screen that asks patients how they took each medication in the past week, a 2-item Belief Screen
that asks about drug effects and bothersome features, and a 2-item Recall Screen about potential difficulties remembering.
Validity was assessed in 20 patients using the Medication Events Monitoring System (MEMS). Results varied by type of
non-adherence, with the Regimen and Belief Screens having 80100% sensitivity for repeat non-adherence and the Recall
Screen having 90% sensitivity for sporadic non-adherence. The BMQ appears more sensitive than existing tools and may
be useful in identifying and diagnosing adherence problems. 1999 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Patient compliance; Drug utilization; Measurement; Questionnaire

1. Introduction
and health settings [1]. Studies
show that approxi- mately 25% of all prescribed
doses are omitted by
Patient non-compliance or lack of adherence with patients [2] and that this non-adherence is a signifidrug regimens continues to be a major problem in cant factor in cardiovascular morbidity and mortality,
virtually all medical specialties, patient populations,
rejection of transplanted kidneys, leukemia relapse,
vision loss in glaucoma, and other indicators of
treatment failure [37]. Poor adherence also has
*Corresponding author. Tel.: 1 1 608 2652128; fax: 1 1 608
been implicated in unnecessary and costly proce2623397.
dures and hospitalization in asthma and other conE-mail address: blsvarstad@pharmacy.wisc.edu (B.L. Svarstad)
1
William S. Apple Professor
2

Assistant Professor

0738-3991 / 99 /$ see front matter

PII: S0738-3991( 98 )00107-4

ditions [8]. Researchers have identified many determinants of non-adherence [2,9], specific ways in
which communication between professionals and

1999 Elsevier Science Ireland Ltd. All rights reserved.

11
4

B.L. Svarstad et al. / Patient Education and Counseling 37 (1999) 113 124

patients contributes to non-adherence [911], and This is a serious drawback, because patients often
effective interventions [9,12]. Unfortunately, no sinincrease drug intake a few days before coming to the
gle intervention is totally effective for all patients clinic, giving an erroneous impression of adherence
and it is not yet possible to predict which individual
[19].
or subgroup actually needs a given intervention.
The most innovative and sophisticated method of
Patients also are reluctant to admit non-adherence
measuring adherence is the Medication Events Moniunless clinicians make specific efforts to monitor the
toring System ([MEMS ], Aprex Corporation, Fredegree of adherence on a regular basis [10,11].
mont, CA). The MEMS involves dispensing each
Practitioners therefore need accurate, practical, and
patients medication in a bottle that contains a
clinically relevant tools for screening or detecting
microprocessor in the cap. The microprocessor readherence problems [1316]. Accurate information
cords the date and time of each bottle opening, with
about adherence also is useful in targeting intereach opening counted as a presumptive dose. There
ventions more effectively and efficiently [17], studyis no assurance that patients actually consume their
ing professionalpatient relationships [18], interpretmedication, but they would have to open and close
ing drug effects [4,19], and measuring the outcomes
the bottle at prescribed intervals on a daily basis to
of patient education and disease management procreate a false pattern of adherence. Studies have
grams [20].
demonstrated that MEMS is more accurate than other
Researchers have tested the accuracy of several
available methods and is therefore considered the
methods of detecting non-adherence. Unfortunately,
gold standard of adherence measurement [16,19].
no single method is adequate [16]. One of the
Despite these advantages, this tool has not yet been
earliest methods of measuring non-adherence inapplied widely due to its cost and other practical
volved physician estimates. Findings revealed that
issues that limit its use in large studies and routine
this method was no more accurate than chance alone,
clinical practice [20].
leading researchers to abandon it [13,21]. Later
Self-report measures (face-to-face or telephone
studies showed that pill counts provide useful ininterviews, questionnaires, diaries) provide a practiformation if done in patients homes and the purpose
cal and flexible method of assessing adherence and a
of this assessment is not emphasized beforehand
unique opportunity to identify patient concerns.
[14]. However, home visits are not always feasible
While self-reported adherence has been linked to
and patients often combine medication from several
clinical outcomes [22], there are serious concerns
bottles into a single container, making it difficult to
about the accuracy of these measures due to poor
interpret pill counts [22]. Researchers also have
sensitivity or ability to detect true non-adherence
criticized clinic-based pill counts, because many
[18,32]. In fact seven of eight published studies
patients do not bring containers back to the clinic
examining the validity of self-report adherence mea[23] and those that are returned seriously overestisures show a sensitivity level below 60% (Table 1).
mate adherence when compared to more objective
This means that existing tools incorrectly classify at
methods [19,24].
least 40% of patients with true non-adherence.
Pharmacy refill records and drug claims provide
Stewart [18] attempted to improve this situation by
relatively objective, unobtrusive, and inexpensive
developing a more specific and comprehensive set of
estimates of adherence in large populations over
questions. While her approach yielded excellent
extended periods of time [2528]. However, these
results in patients with new prescriptions (85.5%
methods only provide a gross measure of adherence
sensitivity), it failed to detect most cases of nonand cannot be used for short-term regimens [20].
adherence in patients with refills (40% sensitivity).
Researchers also have used laboratory tests, blood
There are several explanations for the low senpressure readings, and other physiological measures
sitivity of existing self-report measures. First, it is
for detecting non-adherence [13,29,30]; however,
possible that no single tool can detect all types of
these methods are not always available or feasible.
non-adherence and that multiple tools are needed.
Another concern is that these techniques only reflect
For example, Park and Lipman [33] found that their
drug-taking in the day or two before the test [31].
instrument was more sensitive in detecting major

Table 1
a
Studies examining the validity of self-report measures of adherence
Study

Stewart [18]
Morisky et al. [22]
Craig [30]
Inui et al. [15]
Gilbert et al. [13]
Haynes et al. [14]
Gordis et al [29]
Park and Lipman [33]
a

Criterion
b
measure

Pill count; , 100%

New prescriptions
Refill prescriptions
Blood pressure
Lab test
Pill count; , 75%
Pill count; , 81%
Pill count; , 80%
f
Lab tests; , 75%
Pill count; , 100%

Validity of self-report measure

Sensitivity
%
85.5
40.0
e
43.6
40.0
55.3
19.0
50.0
53.8
25.0

PPV
%
70.8
50.0
5
102.
0.0
8
58.
90.
100.
0.0
8
8.

Specificity
%
d
d

81.0
100.0
87.9
92.0
95.8
100.0
100.0

Accur
acy
%
75.5
66.7
69.0
85.0
67.6
70.4
75.4
68.9
59.8

Adapted from Stewart [13]

Table shows criterion for determination of true non-adherence. Studies were included only if objective adherence data were obtained for at
least 80% of eligible subjects.
c
See methods section for definitions of accuracy, sensitivity, positive predictive value (PPV), and specificity.
d
Not reported for patients with new versus renewed prescriptions; specificity was 69.8% for total sample
e
Table shows measures ability to detect non-adherence as measured by blood pressure (24 / 55)
f
Patients were considered nonadherent if , 75% of urine specimens were positive for the prescribed drug over a six month study
period.
b

(repeat) dosage errors than minor (sporadic) dosage

questions that ask how regularly a drug was used
errors. Unfortunately, most studies do not distinguish
[15], narrowly worded questions which mention only
repeat and sporadic non-adherence and simply lump
one or two types of nonadherent behavior such as
them together when calculating sensitivity.
forgetting doses or stopping a medication [22],
Second, survey researchers have developed a
leading questions which prompt or remind patients
number of time-proven techniques for minimizing
about what their doctor expects them to do [13,15],
the different types of reporting errors that are known
and questions which suggest that non-adherence is
to occur when asking people to report the frequency
careless behavior [22]. Whether different types of
of behaviors that are potentially embarrassing, threatquestions and alternative wording yield more accurening, or difficult to report accurately for other
ate self reported adherence is an issue that clearly
reasons [34]. Unfortunately, these survey techniques
deserves further study.
have not been applied rigorously to the design of
The purpose of this study is to test the validity of a
self-report tools for measuring adherence. For exam- new self-report instrument for measuring and moniple, survey methodologists generally recommend toring adherence and barriers to adherence from the
asking about behavior during a specific time period patients perspective. The instrument, referred to as
and using a shorter recall period [34]. However, the Brief Medication Questionnaire (BMQ), builds
existing tools for measuring adherence often use long on existing theory and research about patient adherrecall periods or an unspecified time period [15,29]. ence and survey methodology. Our aims were to
Another limitation of existing tools is that they develop an instrument that is brief and easy to use,
include questions that might be worded more carefulhas good sensitivity or ability to detect different
ly to reduce memory errors, the level of threat or types of non-adherence, and has the potential for
embarrassment experienced by patients who want to self-administration by patients with multiple drugs.
make a favorable impression, and other sources of In this paper, we test the BMQs ability to detect
response error. Examples in the published literature repeat and sporadic non-adherence using a 5-item
include overly broad questions that ask about multiRegimen Screen that asks patients how they took
ple drugs in the same item [14], ambiguously worded
each of their medications in the past week, a 2-item

Belief Screen about drug efficacy and bothersome

features, and a 2-item Recall Screen about remembering difficulties.

2.1. Patient recruitment and data collection

The Medication Event Monitoring System
([MEMS ], Aprex Corporation, Fremont, CA) was
used to evaluate the sensitivity of a 2-page Brief

interviewed in their homes 1 month after enrollment.

The interview was done by a research pharmacist
using the 2-page BMQ. After completing the BMQ,
the researcher asked to see the patients medication
bottles and performed a pill count. If the patient
2. Methods had a MEMS cap, it was collected and
replaced with a standard cap. The research
pharmacist later reviewed medical and pharmacy records to verify
regimens. The researcher was blinded to MEMS
results until all BMQ data were entered into a
computerized file.

Medication Questionnaire (BMQ) that we developed

2.2. MEMS and pill count measures of adherence
for measuring adherence in patients who were prescribed enalapril and captopril (angiotensin-convertMEMS data were used to construct three objective
ing enzyme [ACE] inhibitors). Patients were remeasures of ACE inhibitor adherence: (i) type of
cruited in three pharmacies operated by a Midwestnon-adherence in the past week (repeat, sporadic,
ern health maintenance organization (HMO). Panone), (ii) rate of dose omission in the past week
tients were eligible if they resided in a non-institu(proportion of prescribed doses not taken for 7 days
tional setting, did not use special containers, and had
prior to interview), and (iii) rate of dose omission in
three or more scheduled medications (including
the past month (proportion of prescribed doses not
enalapril or captopril). Eligible patients were aptaken for 30 days prior to interview). Type of nonproached by an HMO pharmacist to determine
adherence fell into three categories: repeat noninterest in the study. Written consent was then sought
by a research pharmacist who was not affiliated with adherence (took $ 20% over or under
number of doses); sporadic
prescribed
the HMO. Patients were informed that they may or
non-adherence (took
119% under or over
may not receive a special container that recorded
prescribed number of doses);
and no noneach opening and that everyone would be interadherence
(tooka 20%
100%cutoff
of prescribed
We used
for repeat non-adher- viewed about medication use four weeks after enroll-doses).
ence to facilitate comparison with past studies [13
ment.
15,29]. To assess the effect of MEMS assignment,
Of 48 eligible patients, only four refused. Consentwe compared rates of dose omission in the past
ing patients were randomly assigned to two groups:
month using pill count data for patients in the
one group received their enalapril or captopril in a
MEMS and non-MEMS groups. Rate of dose omisMEMS container (n 22) and the other group
sion was defined as the proportion of prescribed
received a standard vial (n 5 22). We employed
doses not taken for the past 30 days.
the MEMS, because it provides detailed
information about adherence during a particular
week or month
and is considered the 5
gold standard of adherence
2.3. BMQ measures of adherence and barriers to
measurement [16,19]. It was not possible to blind the
adherence
patient or interviewer as to MEMS and non-MEMS
assignment. However, we were concerned that
In this paper, we analyze three generic screens
MEMS patients might try harder to adhere because
or sets of questions from Part A of the BMQ. The
the MEMS container appears different than a stanfirst screen includes five items that measure adherdard vial. We therefore collected pill count data from
ence behavior and is called the Regimen Screen
MEMS and non-MEMS patients, allowing us to test
for potential non-adherence. It begins with a neutral,
the potential effects of receiving a MEMS container.
open-ended question that asks the patient to list all
Of 44 consenting patients, one was unable to
medications taken in the past week. For each medicomplete the study. The remaining patients were
cation listed, four questions are asked: How many

days did you take it? How many times per day did given medication. For each medication, the patient is
you take it? How many pills did you take each asked: How well does (did) this medication work
time? and How many times did you miss taking a for you? (very well, ok, not well). After reporting
pill? We focused on the past week, because a how well each medication works, the patient is
shorter recall period may reduce reporting error, as asked: Do any of your medications bother you in
suggested earlier. Patients receive a score of 1 if any way?. Patients receive a score of 1 if they
their initial or spontaneous report indicates potential respond not well or dont know when asked nonadherence with the current regimen for the target how well the target medication works for them and a
medication and a score of 0 if this report indicates
score of 1 if the medication was identified as
no non-adherence. Indicators of potential non-adher- bothersome. Item scores are summed to obtain a total
ence including: failing to mention the target medica- belief score, with positive scores indicating one or
tion (without prompting or interviewer assistance),
more belief barriers (range 5 02).
stating that one cannot answer or remember, reportThe third screen is called the Recall Screen and
ing any interruption or discontinuation due to a late
includes two items that measure potential problems
refill or other reason, reporting any missed doses, or
remembering all doses. These barriers are identified
reporting any extra doses. Patient responses to the
by reviewing the dosage regimen and by asking the
five items also are used to calculate the rate of dose
patient How hard is it for you to remember to take
omission (proportion of prescribed doses omitted
all the pills? (very, somewhat, not at all). Patients
according to initial report). (See Appendix A for a
receive a score of 0 they have a single dose
copy of the questions and procedures used to score
regimen (once daily) and report that it is not at all
them).
hard to remember all the pills, a score of 1 if they
After patients finish reporting how each mentioned
have a multiple dose regimen (two or more times per
drug was taken, the interviewer asks one or more
day), or report that it is very or somewhat hard
neutral probes to identify additional medications that
to remember all the pills, and a score of 2 if both
the patient did not mention for some reason (e.g.
indicators are present. The BMQ also asks about
Do you have any other medications that you may
difficulties opening the container, reading labels,
have stopped for some reason?). If the patient
obtaining refills, and other practical issues. However,
identifies additional medications, the interviewer
we have excluded them from the present analysis due
should list them and repeat the above mentioned
to limited variability in this study
population. questions. However, it is important to mark medications listed in the patients initial (spontaneous)
report versus additional medications identified after
any interviewer probes, reminders, or prompts about
3. Data analysis
a specific drug that was omitted from the patients
listing of drugs used in the past week. Patients
To assess the effects of MEMS assignment, we
obviously can forget to mention certain drugs taken
compare rates of dose omission for patients in the
in the past week, but previous work [10] suggests
MEMS and non-MEMS groups using pill count data
that patients who forget to mention a prescribed
and the t-test. We then test the BMQs sensitivity or
drug often have stopped or reduced their use of that
ability to detect true non-adherence, as measured by
drug according to more objective measures. We
MEMS. Standard epidemiologic methods [18,35] are
therefore rely on the patients initial (spontaneous)
used to define and calculate sensitivity, spereport when scoring the Regimen Screen.
cificity, positive predictive value, and overall
The Belief Screen measures two beliefs that have
accuracy of the Regimen, Belief, and Recall
been linked to non-adherence in past studies [9,11].
Screens (Table 2). The Fishers exact test is used to
These particular items address patient concerns or
analyze the relationship between categorical meadoubts about the efficacy of a given medication and
sures of adherence, and Pearson correlation techconcerns about unwanted side effects, short-term or
niques are used to analyze relationships between
long-term risks, or other bothersome features of a
continuous measures of adherence.

Table 2
Calculation of BMQ sensitivity, specificity, positive predictive
value, and overall accuracy

20
medihad

BMQ
(self-report)

Positive screen
Negative screen

Objective criterion (MEMS )

95% were white. Patient age ranged from 30 to 74

years (mean 5 52.6); education ranged from 8 to
years (mean 5 13.8); and number of scheduled

Dosage error
present

Dosage error
absent

a
b
c

cations ranged from 3 to 9 (mean 5 4.5). Patients

been taking their ACE inhibitor for an average of
25.4 months (range, 1 to 96). Twenty one patients
were prescribed captopril and 22 were prescribed

enalapril. Dosage regimens for ACE inhibitors

Sensitivity 5 a /(a 1 c) 3
100.
Specificity 5 d /(b 1 d ) 3 100.
the Positive predictive value (PPV) 5 a /(a 1 b) 3 100.
Overall accuracy 5 (a 1 d )/(a 1 b 1 c 1 d ) 3 100.

How
19%

ranged from once daily (n 5 23) to twice daily (n 5

20). According to the BMQ, 19% (n 5 8) of
patients had a concern or doubt when asked
well is (this) medication working for you?,

Note: BMQ refers to Brief Medication Questionnaire; MEMS

refers to Medication Events Monitoring System; a positive screen
indicates patient reported some non-adherence or barrier to

(n 5 8) identified the ACE inhibitor when asked Do

any of your medications bother you in any way?,
adherence and a negative screen indicates patient did not report
and 34.9% (n 5 15) reported at least one of
these any non-adherence or barrier to adherence.
belief barriers. One of every four patients (n 5
11) also reported that it is at least somewhat hard to
Results
remember to take all the pills.
We compared the characteristics of MEMS and
4.1. Patient characteristics
non-MEMS patients and
found no significant differ- ences by age,
education, race, number of medicaOf 43 patients who completed the study, 21 had a tions, type of ACE inhibitor, duration of treatment,
standard vial and 22 had a MEMS container (Table or dosage regimen (P . 0.05). The MEMS group did
3). Sixty percent of study participants were male and
have a higher proportion of male patients (P 5
0.05);
Table 3
Patient characteristics and adherence by MEMS assignment
Total

Non-MEMS

MEMS

Number of cases

43

21

Patient background
Age, mean years
Sex, % male
Education, mean years
Race, % white
Scheduled drugs, mean no.
Drug type, % captopril
Drug length, mean months
Drug regimen, % multiple doses

52.6
60.5
13.8
95.3
4.5
48.8
25.4
46.5

51.1
42.9
14.0
95.2
4.6
47.6
29.6
47.6

54.0
a
77.3
13.6
95.5
4.5
50.0
21.4
45.4

BMQ and adherence measures

Doubts how well drug works, %
Believes drug is bothersome, %
Reports $ 1 belief barriers, %
Reports remembering problem, %
% doses missed/ week (BMQ)
% doses missed/ week (MEMS)
% doses missed/ month (pill count)
% doses missed/ month (MEMS)

18.6
18.6
34.9
25.6
4.1

10.7

4.8
23.8
28.6
23.8
2.6

10.8

31.8
13.6
40.9
27.3
5.5
19.2
10.5
13.0

22

Chi-square test for non-MEMS versus MEMS group was significant at 0.05 level. No significant differences were found for other
background, BMQ, or adherence measures.

however, patient sex was unrelated to any of the

(or barrier to adherence) in response to a given
subjective or objective adherence measures (P .
screen, whereas, a negative screen indicates that
0.05). To determine the potential effects of MEMS
no non-adherence or barrier was reported.
assignment on adherence, we compared rates of dose
While none of the screens is adequate by itself,
as omission using pill count data for the month follow- a group they yielded better results than might be
ing enrollment. We found no significant difference
expected based on past studies. For example, a
between the proportion of doses omitted in the two
positive Regimen Screen was obtained in four of
five groups (0.105 and 0.108 in MEMS and non-MEMS patients with repeat non-adherence and none of the
group, respectively; F 5 0.0047; P . 0.05). Further 15 remaining patients with sporadic or no nonanalysis of MEMS patients showed a significant
adherence (Panel A). The Regimen Screen
therefore correlation between rate of dose omission as meahad very good sensitivity (4 / 5, 80%),
specificity sured by MEMS and pill count (r 5 0.655; P 5 (15 / 15, 100%), positive predictive
value (4 / 4,
0.001); however, pill counts underestimated the rate
100%), and overall accuracy (19 / 20, 95%)
when of omission in comparison to MEMS (0.105 versus examining the type of non-adherence of
greatest 0.131). We conclude that MEMS did not have a
concern to researchers and clinicians. On
the nega- measurable effect on adherence and that it is a
tive side, it failed to detect non-adherence
in patients suitable method for testing the BMQ. We therefore
with sporadic non-adherence (0 / 10, 0%
sensitivity). restrict the following analysis to patients for whom
The 2-item Belief Screen also
performed well. A MEMS data were available.
positive Belief Screen was obtained for all patients
with repeat non-adherence and 3 of 15 patients with
4.2. Prevalence of non-adherence according to
sporadic or no non-adherence (Panel B). This
re- MEMS
sulted in a 100% sensitivity
level (5 / 5), 80% specificity (12 / 15), 62%
positive predictive value
Twenty patients provided usable MEMS data for
(5 / 8), and an overall accuracy of 85% (17 / 20) with
the week prior to the home interview. Of these respect to repeat non-adherence. Like the Regimen
patients, 15 did not adhere fully to the prescribed Screen, the Belief Screen failed to identify sporadic
regimen during the week prior to the interview. non-adherence: only 1 of 10 patients with this type Onefourth of the patients had repeat non-adherence of non-adherence was identified, yielding a sensitivi- (took $
20% more or less than prescribed); one-half
ty level of 10%.
had sporadic non-adherence (took 119% more or
A different picture emerged when we tested the
less than prescribed); and one-fourth had no nonRecall Screen (Panel C). In contrast to the other
adherence in the past week. Of those with nonscreens, the Recall Screen had poor sensitivity (40%)
adherence, all except one took less than prescribed.
when examining repeat non-adherence and good
Overall, patients omitted 19.2% of the prescribed
sensitivity for sporadic non-adherence. Of 10 padoses in the past week and 13.1% of the prescribed
tients with sporadic non-adherence, 9 had a recall
doses in the past month, suggesting that patients did
barrier. This resulted in good sensitivity (90%),
not increase their drug-taking in the week prior to the
specificity (80%), and overall accuracy (85%) when
BMQ interview.
examining this type of non-adherence. A summary of
these findings and statistical results is provided in
4.3. BMQs ability to predict repeat and sporadic
Table 4.
non-adherence
4.4. BMQs ability to predict rates of dose
Fig. 1 shows the BMQs ability to predict any
omission in past week and month
non-adherence in patients with repeat and sporadic
non-adherence according to MEMS. We present
When we compared rates of dose omission, we
results of the Regimen, Belief, and Recall Screens in found a strong correlation between the reported rate
Panels AC, respectively. A positive screen indi- of omission using the Regimen Screen and the true
cates that the patient reported some non-adherence
rate of dose omission in the past week (r 5
0.67;

Fig. 1. Comparison of BMQ and MEMS measures of adherence.

Table 4
Validity of BMQ by type of screen and type of non-adherence according to MEMS, n 5 20
Type of screen and a
type of non-adherence

Regimen Screen
Repeat non-adherence
Sporadic non-adherence
Belief Screen
Repeat non-adherence
Sporadic non-adherence
Recall Screen
Repeat non-adherence
Sporadic non-adherence
a

Validity of BMQ screen

Sensitivity
(%)

PPV
(%)

Specificity
(%)

Accuracy
(%)

100.0

100.0

95.0

37.5

70.0

62.5
12.5

80.0
42.9

85.0
25.0

40.0
c
90.0

18.2
81.8

40.0
80.0

40.0
85.0

80.0

0.0
100.0
10.0

Type of non-adherence in past week according to MEMS : repeat 5 took at least 20% over or under the prescribed
amount; sporadic 5 took 119% over or under the prescribed amount.
b
See Table 2 for definition of sensitivity, positive predictive value (PPV), specificity, and accuracy.
c
Fishers exact test, P , 0.01 (1-tailed).

B.L. Svarstad et al. / Patient Education and Counseling 37 (1999) 113 124

121

P 5 0.001) and past month (r 5 0.89; P 5 0.001) more difficult to report due to its unintentional,
according to MEMS. Findings also showed signifi- infrequent, or erratic nature. Patients seem aware of
cant correlations between the total Belief Screen their remembering difficulties, but unable to pinpoint
score and true rate of dose omission in the past week when or how often they occur. In contrast, repeat
(r 5 0.71; P 5 0.001) and past month (r 5 0.61;
non-adherence probably reflects deliberate
changes
, 0.01). In contrast, there was a slightly negative in the regimen by patients who have unresolved
but non-significant relationship between the patients concerns or doubts about the drug and how it is
score on the Recall Screen and actual rate of dose affecting them. While these patients may be reluctant
omission in the past week (20.13; ns) and past to disclose the full extent of their non-adherence,
month (20.08, ns). These findings are consistent many admit at least some non-adherence and concern
with earlier results and reinforce the importance of about a particular drug regimen when asked carefully
using several tools and assessing different types of worded questions designed to reduce the different nonadherence.
types of reporting errors that can occur in this
context.
Our results are encouraging, because they are
5. Discussion
based on a test population with
multiple drugs and refill prescriptions, factors
known to reduce the
Our results are consistent with previous studies sensitivity of self-report adherence measures [18].
which show that patients generally under report their Larger studies in other settings clearly are needed to
non-adherence. However, it is clear that the sensitiviassess BMQ performance in patients with other
ty and overall accuracy of self-report measures can
characteristics. Further research also is needed to test
be improved by employing established principles of the BMQs ability to predict future behavior and to
survey methodology. By applying these principles determine how BMQ results are affected by variamore rigorously, we obtained a Regimen Screen with
tions in interviewer training and background, how
a sensitivity level of 80%, a positive predictive value and where the instrument is administered, number of
and specificity level of 100%, and an overall accuraadministrations, modifications in question wording
cy of 95%. These results compare favorably to and order, interviewer reactions or attempts to
published self-report adherence tools, which show an change patient behavior and beliefs, and alternative
average sensitivity level of approximately 46% and
methods of scoring. Any of these could influence
an average accuracy level of 71% (Table 1). We also
interview or questionnaire results.
found strong correlations between the reported rate
of omission in the past week and true rates of
omission in the past week and past month (r 5 0.67
6. Practice implications
and r 5 0.89, respectively). These findings also
compare favorably with past studies which show
Clinical studies are needed to evaluate the BMQs
correlations between subjective and objective adherutility in various medical and pharmacy practice
ence measures ranging from 0.43 to 0.74 [14,22,30].
settings. However, we believe it can add important
Our study is among the first to demonstrate that
dimensions to adherence monitoring and enhance
sensitivity levels vary by type of non-adherence and
communication between patients and their care givtype of screening tool. We found that the Regimen
ers. First, it provides a clinically relevant and flexible
and Belief Screens had good sensitivity when exmethod of screening non-adherence in patients with
amining repeat non-adherence and poor sensitivity
diverse drugs and drug regimens. When and how
with regard to sporadic non-adherence, whereas, the
often it is administered depends on the patient
Recall Screen had good sensitivity with regard to
population and how the information will be used.
sporadic non-adherence and poor sensitivity with
Second, it has excellent potential for self-administraregard to repeat non-adherence. We suspect that
tion by patients, thus providing an inexpensive and
sporadic non-adherence is under reported in the
easy-to-use tool for screening adherence on a regular
Regimen Screen, largely because this behavior is
basis. Additional time, training, and reallocation of

tasks often are necessary in any effort to improve

goals and outcomes, assistance in using home monicommunication between professionals and patients;
toring devices, and/ or supports known to
enhance however, busy practitioners should be able to test the
motivation and satisfaction with
therapy. After inter- utility of BMQ items with minimal effort.
ventions have been implemented,
BMQ items can be Third, the Belief and Recall Screens can help
used to evaluate outcomes. BMQ
data also can be diagnose and potentially resolve different types of
entered into various
databases and used in continu- adherence barriers. Initially, the questions can be
ous
quality improvement programs. It is important to used as screening tools to identify, classify, and
explore these different clinical applications if we are
document patient concerns requiring further assessto gain a better understanding of the potential
ment and follow-up. Once specific concerns have
advantages and disadvantages of the BMQ and other
been evaluated, appropriate interventions can be
self report tools for measuring and monitoring
developed in consultation with patients and other
adherence problems and concerns.
care givers. Patients with recall barriers can be given
simpler regimens, assistance in tailoring regimens to
fit daily routines, special containers or memory aids,
or other support designed to increase remembering.
Acknowledgements
Patients with unwanted side effects or bothersome
features can be referred for medical evaluation and
This research was supported in part by a grant
counseling, evaluated as candidates for less bother- from the National Corporation of Swedish Pharsome medications, given appropriate reassurance, or macies. We thank all patients, pharmacists, and clinic
offered other assistance in coping with bothersome staff who participated in the study and our colleagues
aspects of therapy. Patients with concerns about and students who provided helpful suggestions. We
efficacy can be given further counseling and feed- especially thank Ingegard Agernas, Larry Boh, and
back, greater involvement in evaluating treatment
Cynthia Raehl.

B.L. Svarstad et al. / Patient Education and Counseling 37 (1999) 113 124

123

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