Open Access Open Access  Restricted Access Subscription or Fee Access

Translation and validation study of Morisky Medication Adherence Scale (MMAS): the Urdu version for facilitating person-centered healthcare in Pakistan

Fahad Saleem, Mohamed Azmi Hassali, Shafie Akmal, Donald E. Morisky, Muhammad Atif, Harith Kh Al-Qazaz, Imran Masood, Noman ul Haq, Hisham Aljadhey, Maryam Farooqui


Objective: The study aims to translate and examine the psychometric properties of the Urdu version of Morisky Medication Adherence Scale (MMAS) among hypertensive patients in Quetta, Pakistan.

Method: A standard ‘‘forward–backward’’ procedure of translation was used to translate the English version of MMAS into Urdu. The translated version was than validated on a convenience sample of 150 hypertensive patients attending a public hospital in Quetta, Pakistan, between July and September 2010. The reliability of the translated questionnaire was tested for internal consistency. Validity was confirmed using convergent and known group validity.

Results: Adopting the recommended scoring method, the mean ± SD of MMAS scores was 6.23 ± 0.9. The instrument demonstrated good internal consistency (Cronbach’s a = 0.701). The test–retest reliability value was 0.8 (p < 0.001). A positive correlation between the 8 and 4 item MMAS was found (r = 0.765; p ≤ 0.01). There was a significant relationship between MMAS categories and the hypertension control groups (χ2 = 19.996; p < 0.001). The MMAS sensitivity and specificity, with positive and negative predictive values, were 46.15%, 60.00%, 45.0% and 61.11%, respectively.

Conclusions: Results from this translation and validation study conclude that the Urdu version of the MMAS is a reliable and valid measure of medication adherence and therefore a valid tool for the advancement of person-centered healthcare.


Adherence, adherence scale, Morisky Medication, person-centered healthcare, translation, Urdu, validation

Full Text:



Pakistan Medical Research Council. (1998). National Health Survey of Pakistan, 1990-1994. Karachi, Pakistan. Available from

Saleem, F., Hassali, A.A. & Shafie, A.A. (2010). Hypertension in Pakistan: time to take some serious action. British Journal of General Practice 60, 449-450.

Mohan, S., Campbell, N. & Chockalingam, A. (2005). Management of hypertension in low and middle income countries: Challenges and opportunities. Prevention and Control 1, 275-284.

Rose, A.J., Berlowitz, D.R., Orner, M.B. & Kressin, N.R. (2007). Understanding Uncontrolled Hypertension: Is It the Patient or the Provider? Journal of Clinical Hypertension 9, 937-943.

Lüscher, T.F., Vetter, H., Siegenthaler, W. & Vetter, W. (1985). Compliance in hypertension: facts and concepts. Journal of Hypertension 3, s3-s9.

Mant, J. & Mcmanus, R.J. (2006). Does it matter whether patients take their antihypertensive medication as prescribed? The complex relationship between adherence and blood pressure control. Journal of Human Hypertension 20, 551-553.

Nichols-English, G. & Poirier, S. (2000). Optimizing adherence to pharmaceutical care plans. Journal of the American Pharmacists Association 40, 475-485.

Alexander, M., Tekawa, I., Hunkeler, E., Fireman, B., Rowell, R., Selby, J.V., Massie, B.M. & Cooper, W. (1999). Evaluating hypertension control in a managed care setting. Archives of Internal Medicine 159, 2673-2677.

Stockwell, D.H., Madhavan, S., Cohen, H., Gibson, G. & Alderman, M.H. (1994). The determinants of hypertension awareness, treatment, and control in an insured population. American Journal of Public Health 84, 1768-1774.

Lafleur, J. & Oderda, G.M. (2004). Methods to measure patient compliance with medication regimens. Journal of Pain & Palliative Care Pharmacotherapy 18, 81-87.

Mcdonnell, P.J. & Jacobs, M.R. (2002). Hospital admissions resulting from preventable adverse drug reactions. The Annals of Pharmacotherapy 36, 1331-1336.

Senst, B.L., Achusim, L.E., Genest, R.P., Cosentino, L.A., Ford, C.C., Little, J.A., Raybon, S.J. & Bates, D.W. (2001). Practical approach to determining costs and frequency of adverse drug events in a health care network. American Journal of Health-System Pharmacy 58, 1126-1132.

World Health Organization. (2003). Chapter XIII Hypertension in Adherence to Long- Term Therapies-Evidence for Action. Available from:>

Dimatteo, M.R. (2004). Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Medical Care 42, 200-209.

Haynes, R.B., Mcdonald, H.P. & Garg, A.X. (2002). Helping patients follow prescribed treatment. Journal of the American Medical Association 288, 2880-2883.

Krousel-Wood, M., Hyre, A., Muntner, P. & Morisky, D. (2005). Methods to improve medication adherence in patients with hypertension: current status and future directions. Current Opinion in Cardiology 20, 296-300.

Osterberg, L. & Blaschke, T. (2005). Adherence to medication. New England Journal of Medicine 353, 487-497.

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

Donnan, P.T., Macdonald, T.M. & Morris, A.D. (2002). Adherence to prescribed oral hypoglycaemic medication in a population of patients with Type 2 diabetes: a retrospective cohort study. Diabetic Medicine 19, 279-284.

Rcmar Measurement Tools. (2006). Measuring Medication Adherence. Available from:

Al-Qazaz, H.K., Hassali, M.A., Shafie, A.A., Sulaiman, S.A., Sundram, S. & Morisky, D.E. (2010). The eight-item Morisky Medication Adherence Scale MMAS: Translation and validation of the Malaysian version. Diabetes Research and Clinical Practice 90, 216-221.

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, 67-74.

Morisky, D.E., Ang, A., Krousel-Wood, M. & Ward, H.J. (2008). Predictive validity of a medication adherence measure in an outpatient setting. The Journal of Clinical Hypertension 10, 348-354.

Trindade, A.J., Ehrlich, A., Kornbluth, A. & Ullman, T.A. (2010). Are your patients taking their medicine? Validation of a new adherence scale in patients with inflammatory bowel disease and comparison with physician perception of adherence. Inflammatory Bowel Diseases 17, 599-604.

Institute for Health and Care Research. (2010). Questionnaires: selecting, translating and validating. Available from:

Harkness, J.A., & Schoua-Glusberg, A.S. (1998). Questionnaires in translation. In: Cross-cultural survey equivalence (ZUMA-Nachrichten Spezial 3), J.A. Harkness ed., pp. 87-126. Mannheim, Germany: ZUMA.

Behling, O. & Law, K.S. 2000. Translating questionnaires and other research instruments: Problems and solutions. Thousand Oaks, CA: Sage Publications, Inc.

Santos, J.R.A. (1999). Cronbach’s alpha: A tool for assessing the reliability of scales. Journal of Extension 37, 1-5.

Sakthong, P., Chabunthom, R. & Charoenvisuthiwongs, R. (2009). Psychometric Properties of the Thai Version of the 8-item Morisky Medication Adherence Scale in Patients with Type 2 Diabetes. Annals of Pharmacotherapy 43, 950-957.

Södergård, B., Halvarsson, M., Tully, M.P., Mindouri, S., Nordström, M.L., Lindbäck, S., Sönnerborg, A. & Lindblad, Å.K. (2006). Adherence to treatment in Swedish HIV infected patients. Journal of Clinical Pharmacy and Therapeutics 31, 605-616.



  • There are currently no refbacks.