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Psychometric Evaluation of Medication Adherence Rating Scale (MARS)

among Nigerian Patients with Schizophrenia

Article in Nigerian Journal of Clinical Practice · September 2019

DOI: 10.4103/njcp.njcp_325_18

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 Vol. 22, Issue 9, September 2019

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Nigerian Journal of Clinical Practice • Volume 22 • Issue 9 • September 2019 • Pages ***-***
Original Article

Psychometric Evaluation of Medication Adherence Rating

Scale (MARS) among Nigerian Patients with Schizophrenia
OA Sowunmi, PO Onifade

Department of Clinical Background: The Medication Adherence Rating Scale (MARS) is a 10‑item

Abstract
Services, Neuropsychiatric
self‑report measure of medication adherence in psychosis which is a vital
Hospital Aro, Abeokuta,
Ogun, Nigeria predictor of illness course and outcome in patient with schizophrenia. The initial
and subsequent studies have shown that MARS has good reliability and validity
scores after correction for the small sample size in the index study. Aim: This
study aimed to determine the psychometric properties of MARS among outpatients
with schizophrenia at the outpatient clinic of the Neuropsychiatric Hospital Aro
Abeokuta Ogun State Nigeria. Methods: Intra‑class correlation coefficient (ICC)
was used to determine the internal consistency, item‑total correlations,
and reliability of the instrument. Factor analysis was done using principal
component analysis with varimax rotation. Results: The intra‑class correlation
coefficient (ICC) for these 10 items (at time T1) was 0.6 with a P value of <0.001
while for the test‑‑retest analysis was 0.7 with a P value of 0.04. A principal
components factor analysis with varimax rotation produced a four‑factor solution
and factor 4 was found to be the most internally consistent, with Cronbach’s alpha
of 0.63. Conclusion: This study supports the internal consistency, test‑‑retest
reliability, and constructs validity of the MARS.
Date of Acceptance:
02-Mar-2019 Keywords: Adherence, MARS, Nigeria, schizophrenia

Introduction However, adherence and nonadherence with these

T he use of psychotropic medications are primarily
indicated for the treatment of mental disorders
including schizophrenia and other psychotic and
non‑psychotic mental disorders.[1] These medications
are effective in treating symptoms associated with
several mental disorders especially if adherence to
medication is optimal.[2] Medication adherence may be
defined as the degree to which a patient’s medication
use complies or aligns with the recommendations
and advise of the prescribing physician while
‘‘nonadherence’’ includes both underuse and overuse of
medication prescribed.[3]
In previous studies,[2‑4] ‘‘medication nonadherence’’ is
considered to be an ‘‘all or none’’ phenomenon where
the patient is ‘‘nonadherent’’ if they miss 20% of the
medication, which may lead to increased risk of relapse
or (re‑) hospitalization.[3]
medications is a dynamically changing behaviour that
contributes significantly to resolution of symptoms
and reintegration into the society.[2] When compared
with no medication, psychotropic medications
significantly reduce relapse rates in patients with
psychiatric disorders who are stabilized on medications
over 1 year.[3]
Unfortunately, nonadherence is not uncommon and
medication nonadherence in patients with psychiatric
morbidities are reported to range from 20% to 89%.[2,3]
More than 50% of the patients with mental disorders,
especially schizophrenia, become partially adherent or
nonadherent in 1 year, and about 75% in 2 years.[3,5]
Address for correspondence: Dr. OA Sowunmi,
Consultant Emergency Psychiatrist, Neuropsychiatric
Hospital, Aro, PMB 2002, Abeokuta, Ogun, Nigeria.
E‑mail: sowunmioladipo@yahoo.com

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DOI: 10.4103/njcp.njcp_325_18

How to cite this article: Sowunmi OA, Onifade PO. Psychometric evaluation
PMID: ******* of medication adherence rating scale (MARS) among Nigerian patients with
schizophrenia. Niger J Clin Pract 2019;22:1281-5.

© 2019 Nigerian Journal of Clinical Practice | Published by Wolters Kluwer ‑ Medknow 1281
 Sowunmi and Onifade: Psychometric evaluation of medication adherence rating scale (MARS) among nigerian patients with schizophrenia
From the foregoing, it is paramount that medication
adherence be monitored effectively. There are
three main methods of doing this, namely, patient
and clinical self‑report, pill counts, and biological
measures. Self‑report methods are generally the most
cost‑effective and time‑efficient way of obtaining an
indication of adherence,[6] although such methods
have been reported to overestimate adherence by
30%. It may also be dependent on the phrasing of
the question.[6,7] In comparison, pill counts have the
disadvantage of undermining the therapeutic relationship
and are also unreliable since there is no guarantee that
the tablets removed from the container were actually
consumed.[8] Biological measures are less frequently
used due to their cost and limited availability.[6‑8] The
accuracy of biological measurement is compromised
by individual differences in metabolism, and is
dependent on the period of time between ingestion of
the last tablet and testing.[7] None of these methods of
adherence measurement is completely accurate,[6] and
the concordance rate across these different measures
has been reported to be low.[8] Self‑report measures are
perhaps the easiest to administer and the least costly,
whereas biological methods are more objective and
expensive but no more accurate.[3,8]
One of the common use of self‑report questionnaire for
monitoring of medication adherence is the Medication
Adherence Rating Scale (MARS) which was developed
by Thompson et al. in 2000 to be a quick, nonintrusive,
and a simple self‑reporting measure of medication
adherence especially in psychiatric.[1,3,6,9] Despite the wide
use of the instrument in Nigeria, it has few published
psychometric properties in Nigeria.[5,10] Thus, the aim of
this study was to determine the validity and reliability
of MARS among outpatients with schizophrenia at the
outpatient clinic of the Neuropsychiatric Hospital Aro
Abeokuta Ogun State.
Methodology
Study site
The study centre was Neuropsychiatric Hospital, Aro
Abeokuta Ogun State, Nigeria. The hospital has a total
bed capacity of 546 for inpatient care. The hospital
plays a strategic role in mental health care for patients
from all parts of Nigeria and neighbouring countries. All
new patients are seen at the Assessment/Emergency unit
of the hospital from where they are transferred to either
the outpatient clinic or the wards. Those discharged
from the wards are also subsequently followed‑up
at the outpatient clinic. No new patient is seen at the
outpatient clinic of the hospital. The clinic runs on
Mondays, Tuesdays, Thursdays, and Fridays. About
130 patients were seen daily at the outpatient clinic.
1282 Nigerian Journal of Clinical Practice ¦ Volume 22 ¦ Issue 9 ¦ September 2019
Of these, 54 (41.9%) are patients with a diagnoses of
schizophrenia.[11]
Sample size determination
The sample size (n) calculation and oversampling was
calculated as proposed by Cochrane.[12] The calculation
gave a total sample size (n) of 220.
The instrument
The MARS is a 10‑item self‑report instrument in
which a yes/no response is given to questions asked.[8]
It was developed from two previous scales, the 30‑item
Drug Attitudes Inventory (DAI) by Hogan et al.
and the four‑item Morisky Medication Adherence
Questionnaire (MAQ).[8] The aim was to develop a more
reliable and valid tool for assessing medication adherence
behaviour in patients with psychosis. The total scores
range from 0 (low likelihood of medication adherence) to
10 (high likelihood).[8] This shows an understanding that
adherence is a continuous variable and that an individual
can reach a decision anywhere between complete
adherence and complete nonadherence. Adherence is
usually equivalent to scores greater than 5.[8] The 10‑item
MARS can be found on Table 1.
The development sample for the MARS consisted of
66 participants with psychosis and the scale showed
good internal consistency (alpha = 0.75). Three factors
were identified. These were considered to represent
“medication adherence behaviour” (items 1‑4),
“attitude toward taking medication” (items 5–8), and
“negative side‑effects and attitudes to psychotropic
medication” (items 9, 10). A positive correlation of 0.6
between the MARS adherence score and blood lithium
levels suggested construct validity.[8]
Study design
This is a study of diagnostic accuracy. Participants
were selected by systematic random sampling of every
4th patient registered to be seen at the outpatient clinic
of the hospital. A total of 220 respondents who had
diagnosis of schizophrenia were older than 18 years
and were able to read and write in English participated
in the first stage. However, for the retest stage of
the study, 114 respondents could be reached, the rest
were lost to follow‑up. Ethical approval was obtained
from the research and ethics committee of the hospital
and permission was obtained from the managing
consultants. Consent was obtained from all participants
and attention of the managing consultants was drawn
to their corresponding patients who had problems with
medication adherence.
Data Analysis
Data was analyzed using the Statistical Package for
 Sowunmi and Onifade: Psychometric evaluation of medication adherence rating scale (MARS) among nigerian patients with schizophrenia

Social Science (SPSS version 21) Computer Software. the test‑‑retest reliability of the instrument using total
The level of significance was set at P = <0.05. Intraclass score at test and retest. Factor analysis using principal
correlation coefficient (ICC) was used to determine the component analysis with varimax rotation was used
internal consistency of the instrument using responses to confirm the robustness of the original construct.
from the first test. ICC was also used to determine Item‑‑total correlations was also done with intraclass
correlation coefficient using two‑way mixed method
Table 1: 10‑item medication adherence rating with absolute agreement to determine the concurrent
scale (MARS) validity of the questionnaire.
No. Questionnaire Question Answer
1. Do you ever forget to take your Yes/No Result
medication? A total of 240 participants were recruited but 20
2. Are you careless at times about taking Yes/No were excluded because of incomplete questionnaire.
your medication?
The mean MARS score for the 220 participants was
3. When you feel better, do you sometimes Yes/No
stop taking your medication? 7.09 (SD = 2.08), with a range of 1‑10 and the median
4. Sometimes if you feel worse when you Yes/No score of 7. The ICC for these 10 items (at time T1)
take the medication, do you stop taking it? was 0.6 with a P value of < 0.001. The ICC for the
5. I take my medication only when I am sick Yes/No test‑‑retest analysis was 0.7 with a P value of 0.04.
6. It is unnatural for my mind and body to be Yes/No Other details of the analysis can be found on Table 2.
controlled by medication
7. My thoughts are clearer on medication Yes/No A principal components factor analysis with varimax
8. By staying on medication, I can prevent Yes/No rotation, retaining factors with an Eigenvalue greater than
getting sick. 1, produced a four‑factor solution. See Tables 3 and 4.
9. I feel weird, like a “zombie” on Yes/No After rotation, factor 1 (items 1 and 2) accounted for
medication 24.65% of the variance, factor 2 (items 4, 6, 9, and
10. Medication makes me feel tired and Yes/No 10) for 12.99%, factor 3 (3 and 5) 12.88%, and factor
sluggish 4 (7 and 8) for 11.20%. Thus, in total the rotated factor

Table 2: Internal consistence and test‑retest analysis of 10‑item medication adherence rating scale (MARS)
Intra‑class Correlation Coefficient (At T1)
Intra‑class 95% Confidence Interval F Test with True Value 0 df1 df2 Sig
Correlationb Lower Bound Upper Bound Value
Single Measures 0.131a 0.095 0.175 2.509 197 1773 0.000
Average Measures 0.601c 0.513 0.679 2.509 197 1773 0.000
Intra‑class Correlation Coefficient (Test‑‑Retest)
Single Measures 0.528a 0.380 0.649 3.237 111 111 0.000
Average Measures 0.691c 0.551 0.787 3.237 111 111 0.000
Two‑way mixed effects model where people effects are random and measures effects are fixed. a The estimator is the same, whether the interaction
effect is present or not. b Type C intra‑class correlation coefficients using a consistency definition‑the between‑measure variance is excluded
from the denominator variance. c This estimate is computed assuming the interaction effect is absent, because it is not estimable otherwise.
ANOVA (At T1)
Sum of Squares df Mean Square F Sig
Between People 86.015 197 0.437
Within People Between Items 86.394 9 9.599 55.168 0.000
Residual 308.506 1773 0.174
Total 394.900 1782 0.222
Total 480.915 1979 0.243
Grand Mean=1.58
ANOVA (Test‑‑Retest)
Sum of Squares df Mean Square F Sig
Between People 641.357 111 5.778
Within People Between Items 7.875 1 7.875 4.412 0.038
Residual 198.125 111 1.785
Total 206.000 112 1.839
Total 847.357 223 3.800
Grand Mean=16.20

Nigerian Journal of Clinical Practice ¦ Volume 22 ¦ Issue 9 ¦ September 2019 1283

 Sowunmi and Onifade: Psychometric evaluation of medication adherence rating scale (MARS) among nigerian patients with schizophrenia

Table 3: Principal components factor analysis of 10‑item medication adherence rating scale (MARS)
Total Variance Explained
Factor Initial Eigenvalues Extraction Sums of Squared Loadings Rotation Sums of Squared Loadings
Total % of Variance Cumulative % Total % of Variance Cumulative % Total % of Variance Cumulative %
1 2.465 24.650 24.650 1.890 18.900 18.900 1.210 12.096 12.096
2 1.299 12.990 37.640 0.723 7.234 26.134 1.111 11.111 23.207
3 1.288 12.879 50.519 0.693 6.927 33.062 0.861 8.608 31.815
4 1.120 11.196 61.715 0.580 5.801 38.863 0.705 7.048 38.863
5 0.887 8.867 70.582
6 0.692 6.923 77.506
7 0.659 6.595 84.101
8 0.575 5.752 89.852
9 0.570 5.705 95.557
10 0.444 4.443 100.000
Extraction Method: Principal Axis Factoring

Table 4: Rotated component matrix of 10‑item it was higher than the value reported by Fialko
medication adherence rating scale (MARS) et al. (alpha = 0.60).[8] Fialko opined that this may not
Rotated Component Matrixa represent a weakness of the scale because instrument
Component like MARS with binary response choice, small number
1 2 3 4 of items, and scale multidimensionality are expected
MARS test1 0.817 to have lower alpha values. In addition, Fialko et al.
MARS test2 0.714 0.232 0.120 reported that it is likely that the internal consistency of
MARS test9 0.778 0.246 0.177 the MARS could be improved either by adding more
MARS test10 0.187 0.776 response options or by adding more items, it is debatable
MARS test6 0.536 ‑0.169 whether this would constitute an improvement to the
MARS test5 ‑0.146 0.827 measure, or whether it would compromise its quick,
MARS test4 0.242 0.264 0.618 simple format.
MARS test3 0.523 0.567
MARS test8 0.273 0.100 ‑0.171 0.798 This study produced a four‑factor component for
MARS test7 ‑0.232 ‑0.172 0.179 0.766 MARS and the current study also examined the
Extraction Method: Principal Component Analysis. Rotation Method: relationships of the individual factor scores. These
Varimax with Kaiser Normalization. a=Rotation converged in 6 factors correlation was almost of equal strength to the
iterations whole scale correlation. At the development of MARS,
three factors were identified. These were considered to
solution accounted for 61.72% of the total variance. The represent “medication adherence behaviour” (items 1‑4),
internal consistency of the four factors was examined and “attitude toward taking medication” (items 5–8), and
factor 4 (which only consisted of two items) was found “negative side‑effects and attitudes to psychotropic
to be the most internally consistent, with Cronbach’s medication” (items 9, 10). In our study, factor 1
alpha of 0.63. Factor 1 had of 0.57, and factor 2 had a contained items 1 and 2 which corresponded to the
value of 0.55 and factor 3 had a of 0.54. medication adherence behaviour factor of the initial
study. Factor 4 contained 7 and 8 which corresponded
Discussion to the attitude towards medication and factor 2
The following range of MARS total scores (1‑10) was contained items 4, 6, 9, and 10 which corresponded to
present in this sample of individuals who attended the the negative side‑effects and attitudes to psychotropic
outpatient clinic of the Neuropsychiatric Hospital Aro medication.
Abeokuta, indicating widely varying attitudes towards
In the initial study, item 6 loaded on the attitude towards
taking prescribed medications. Our results show that
medication factor which is also included in the negative
the MARS is reliable even over a long interval of
side‑effects and attitudes to psychotropic medication
12 months, although we had an attrition rate of 48.1%.
factor and thus may not be out of place in this study.
The internal consistency of the MARS was Furthermore, item 4 loaded on the medication adherence
moderate (alpha = 0.69), but lower than the value behaviour factor of the initial study but on factor 2
produced by Thompson (alpha = 0.75) and in another which corresponded to the negative side‑effects and
study done in Nigeria (alpha = 0.76).[7,10] However, attitudes to psychotropic medication of the initial study.

1284 Nigerian Journal of Clinical Practice ¦ Volume 22 ¦ Issue 9 ¦ September 2019

 Sowunmi and Onifade: Psychometric evaluation of medication adherence rating scale (MARS) among nigerian patients with schizophrenia
It appears that item 4 was viewed more as an attitude
rather than a behaviour by the participants of this study
and may have influenced the loading observed in this
study. It has been earlier suggested[8] that the finding that
attitude may not translate into adherence behaviour may
not be surprising when the multiple factors involved
in determining adherence behaviour are considered. It
is possible that people with a positive attitude towards
medication may forget to take it while others with
a negative attitude may take medication to please
someone else especially those that might be regarded as
significant others. Factor 3 (items 3 and 5) appeared to
have correlated with insight into illness and insight into
the effects of medication.
It therefore appears that where the concern is simply
whether or not someone is taking their medication, factor
1 (items 1 and 2) and 4 (items 7 and 8) may be a better
indicator than the whole MARS scale. This four item
subscale (items 1, 2, 7, and 8) (which corresponds to
Morisky’s MAQ), from which the MARS was developed
is quicker to administer, and appears valid for this purpose.
The current study has a number of limitations. The
interval between the initial test and the second test
varied across participants which were influenced by
various social and clinical factors of the patients
determined by the attending psychiatrists. Some
patients had as much as 6 month interval between
clinic visits. However, this study is not without its
strength. The sample was not mixed (containing only
outpatients), and was an improvement suggested by an
earlier study.[8]
In summary, the MARS is a quick, nonintrusive measure of
medication adherence. Items in the MARS about attitude
to medication may be informative to clinicians identifying
barriers to adherence in individual cases, but do not appear
to be valuable in predicting adherence behaviour over a
large sample. Factor 1 and 4, corresponding to the MAQ,
may be superior for this purpose.
In conclusion, the study supports the internal
consistency, test‑‑retest reliability, and construct validity
of the instrument.
Nigerian Journal of Clinical Practice ¦ Volume 22 ¦ Issue 9 ¦ September 2019
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Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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