Activating menopause patients to improve outcomes

The Patient Activation Measure (PAM) and Medication Adherence Questionnaire (MAQ) are tools that providers can use to evaluate patients’ health behavior.
The PAM can be used to evaluate patients’ ability to manage their health and conditions; the MAQ can be used to evaluate patients’ level of adherence to their prescribed therapies.
Providers can use the PAM and MAQ 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 previously mentioned in this series, demographic and health trends are increasing the need for healthcare services tailored to menopausal and post-menopausal women. Similar to chronic conditions, patients’ self-management of the menopause transition, including adherence to therapeutic recommendations, may be the single greatest determinant of their prognosis¹

A variety of validated quantitative measures have been developed for characterizing health behavior in the context of supporting patients in the self-management of their chronic conditions. While their application to menopause symptoms is largely unexplored in the literature, given the similarity of menopause to chronic conditions in terms of the complexity, duration, and variability of the symptoms, such tools may be useful for women experiencing menopause symptoms. 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 therapy adherence.²
and can provide important insight into patients’ behavior, beliefs, and barriers to therapy adherence. Healthcare providers can use the information from these measures to provide targeted interventions and personalize patient care. The Patient Activation Measure (PAM)⁴, the Medication Adherence Questionnaire (MAQ), and the Brief Medication Questionnaire (BMQ) are all useful survey tools.³

Emotionally supportive providers who seek to empower patients to take control of their disease self-management have higher levels of patient activation and better outcomes.⁴

The PAM reflects patients’ ability to manage their 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 patients’ willingness and ability to autonomously manage their health and care.⁴

The PAM questionnaire categorizes patients into one of four progressively higher “stages of activation,” described in detail below. The higher activation stages indicate that the patient is more engaged with healthy behaviors such as diet, exercise, and better patient outcomes.^1,4

Patient activation has been linked to positive clinical behavior and improved outcomes; thus, there is significant interest in being able to evaluate and influence patients’ activation stage. The importance of the healthcare provider/patient relationship and effective healthcare provider communication has been well 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.⁴

Medication questionnaires can efficiently quantify patient adherence behavior

In addition to the PAM, scales and surveys specifically quantifying medication adherence already exist, and many 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 MAQ and BMQ are consistently cited as validated exemplars in the literature. ^2,3,5

The MAQ*, also known as the four-item Morisky Medication Adherence Scale (MMAS-4) or the Morisky ³ scale , is the most commonly used medication adherence scale. It is short, simple to use, and has been validated across many different disease areas. ³ Questions for patients with menopause symptoms could include the following:
- Do you sometimes forget to take your medication?
- When you feel like your menopause symptoms are under control, do you sometimes stop taking your medicine?
The BMQ 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 (difficulty remembering to take medication). Despite the name, the BMQ may be more onerous to use at the point of care. Questions for patients with menopause symptoms could include:
- How many medications do you take for menopause symptoms?²
- List all of the current medications you take for your menopause symptoms.

These measures can be administered with relative ease at the point of care. ³ The results provide useful information for healthcare providers seeking to understand their patients’ medication adherence behavior regarding their menopause symptoms and can inform routine clinical practice and non-adherence interventions.

Adherence measures can provide useful insights during routine clinical practice

PAM and medication adherence questionnaires can help healthcare providers to 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 experiencing menopause symptoms:

Stage 1: Disengaged and overwhelmed. The patient does not strongly believe in or understand her role in managing her care. The patient may not take her medication regularly, or even discuss her symptoms with her doctor, because she does not see herself as being responsible for managing the menopause transition.
Stage 2: Aware but struggling. The patient feels responsible for managing her own care and adhering to prescribed therapy but may not follow her doctor’s recommendations because she does not fully understand the value of doing so or because she lacks the confidence needed to act.
Stage 3: Taking action. The patient is fully informed and autonomous. She makes needed lifestyle changes and follows through with her treatment as directed. She may, however, still need additional support to maintain her 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.^6,7

During the patient’s regular check-up, her healthcare provider can use these measures to gain insight to address her menopause symptoms and improve her adherence. Even without administering these specific tools, providers can 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 menopause symptoms?
Do you know what your prescribed medications and therapies do?¹
When you feel like your symptoms under control, do you sometimes stop adhering to your prescribed therapy?²

Healthcare providers can use patients’ responses to tailor the support they need to boost patient activation and improve adherence. A patient who does not see herself as responsible for managing her menopause symptoms may lack elementary knowledge about menopause and the possible outcomes for treated versus untreated menopause symptoms. Healthcare providers can educate patients regarding the transition and the potential to alleviate symptoms and improve quality of life. Similarly, a patient with higher activation may have the necessary skills and knowledge to manage her symptoms and adhere to a treatment plan, but her adherence behavior may be derailed by stress or unexpected life or health events.⁷ Healthcare providers can positively influence activation and adherence by investigating and addressing patients’ questions or concerns and ensuring they know that support is available should any unexpected changes arise that affect adherence.

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 all these tools, in whole or in part, to characterize patients’ needs and provide tailored support. Healthcare providers may have access to interventions based on these theories and developed with input from healthcare experts that can specifically assist with managing menopause symptoms.

The Behavior Change Wheel: A framework for improving menopause therapy adherence

*Please note that MAQ/MPMAS-4 must be purchased by the organizations that wish to use it.

References

Kinney, R. L., Lemon, S. C., Person, S. D., Pagoto, S. L., & Saczynski, J. S. 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; 2015; 98(5): 545-552.
Culig J, & Leppee M. From Morisky to Hill-Bone: Self-report scales for measuring adherence to medication,” Collegium Antropologicum; 2014; 38(1): pp. 55-62.
Lavsa SM, Holworth A, & Ansani NT. Selection of a validated scale for measuring medication adherence. Journal of the American Pharmacists Association; 2011; 51(1): pp. 90-94.
Graffigna G, Barello S, & Bonanomi A. The role of patient health engagement model (PHE-model) in affecting patient activation and medication adherence: A structural equation model. PloS One; 2017; 12(6). 10.1371/journal.pone.0179865
Lam WY, & Fresco P. Medication adherence measures: An overview. BioMed Research International; 2015; EpubBM
Hibbard, J. H., Stockard, J., Mahoney, E. R., & Tusler, M. Development of the patient activation measure (PAM): Conceptualizing and measuring activation in patients and consumers. Health Services Research; 2004; 39(4): Pt. 1, pp. 1005-26.
Gimbel, R., Shi, L., Williams, J. E., Dye, C. J., Chen, L., Crawford, P., … & Truong, K. 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; 2017; 6(3): e38.