BAS-8™: Behavioral Adherence Stability Scale

Introduction

In an era where medication adherence remains one of the most elusive variables in chronic disease management, the BAS-8™ (Behavioral Adherence Stability Scale) introduces a new framework for understanding not only whether patients adhere, but how they navigate their adherence behavior over time. Most tools, including the gold standard MMAS-8, focus on retrospective recall and binary thresholds of adherence. The BAS-8 breaks from this tradition by asking a different kind of question: how stable is a patient's behavioral ecosystem when it comes to medication-taking?

Purpose and Rationale

The BAS-8 was designed to uncover dynamic, situational, and concealed non-adherence behaviors that often precede a measurable decline in adherence or outcomes. Traditional self-report tools ask if the medication was taken; the BAS-8 investigates whether the patient's routine is structurally resilient enough to sustain adherence under real-world stressors. In this sense, the BAS-8 functions as a behavioral seismograph, registering early tremors in adherence behavior before they manifest clinically.

The conceptual foundation of the BAS-8 rests on the insight that behavioral stability is not the same as behavioral success. A patient may report full adherence today but may be one disruption away from collapse. The BAS-8 captures this fragility, quantifies it, and introduces a scalable framework for early detection and tailored intervention.

Structure of the Instrument

The BAS-8 consists of eight situationally anchored, behaviorally focused items that probe different dimensions of behavioral stability in medication-taking over the past four weeks. These dimensions include routine disruption, timing inconsistency, contextual interference, deviation from prescribed use, over-reliance on external reminders, emotional reactivity, medication availability, and routine inconsistency.

Each question uses a tri-level response structure:

• No: (indicates behavioral stability)
• Yes, once:  (suggests moderate instability)
• Yes, more than once: (indicates behavioral instability)

The cumulative score ranges from 0 to 8.

Instructions to Patient

We understand that life can make taking medication challenging. These questions ask about your experience over the past 4 weeks. Please answer honestly. There are no right or wrong answers.

Disrupted Routine

 In the past 4 weeks, did you miss your medication because your usual daily routine was disrupted?
☐ No     ☐ Yes, once   ☐ Yes, more than once 

Timing Changes

 Did you take your medication at a different time than usual (for reasons other than instructions from your doctor)?
☐ No     ☐ Yes, once   ☐ Yes, more than once 

Contextual Barriers

 Did your surroundings (e.g., being in a different place, at work, with others) prevent you from taking your medication?
☐ No     ☐ Yes, once    ☐ Yes, more than once

Deviation from Prescribed Use

 Did you intentionally change how you took your medication (e.g., skipping a dose, taking less or more) without checking with your healthcare provider?
☐ No    ☐ Yes, once   ☐ Yes, more than once

Reliance on External Reminders

 Did you find yourself needing an alarm, another person, or app to remember your medication?
☐ No     ☐ Yes, once    ☐ Yes, more than once 

Emotion-Driven Changes

 Has your mood, stress, or emotions affected whether or how you take your medication?
☐ No     ☐ Yes, once   ☐ Yes, more than once

Medication Unavailable

 Were there times when you didn’t have your medication with you or couldn’t access it when needed?
☐ No     ☐ Yes, once    ☐ Yes, more than once 

Inconsistent Routine

 Was your day-to-day routine inconsistent (e.g. did schedule changes affect your ability to take medications)?  
☐ No     ☐ Yes, once    ☐ Yes, more than once 

Interpretation and Scoring

The BAS-8 is interpreted using behavioral stability tiers:

• Stable (6.0–8.0): The patient displays high resilience in their adherence routines. Even under situational strain, behavior is largely intact.
• Moderately Stable (4.0–5.99): The patient's adherence is functional but contains structural fragilities. External or internal disruptions may compromise adherence in the near future.
• Unstable (<4.0): The patient shows signs of behavioral vulnerability. Immediate intervention may be warranted to prevent clinical consequences.

The BAS-8 is also designed for longitudinal tracking. A change of ≥1.0 point in either direction is considered clinically meaningful and may suggest behavioral improvement or deterioration.

Behavioral Framing and Theoretical Underpinning

Unlike tools grounded purely in self-report adherence status, the BAS-8 draws upon behavioral ecology and cognitive resilience theories. It operates from the premise that patients live within systems of behavior that interact with environment, memory, emotion, and habit. These systems are often stable until disrupted, at which point their fragility becomes visible. By anchoring items in situational realities rather than generic queries, the BAS-8 reduces social desirability bias and increases ecological validity.

This scale does not replace retrospective tools. It complements them by providing forward-looking insight into adherence vulnerability rather than adherence performance. In this way, the BAS-8 is the first instrument to measure the behavioral stability of medication adherence directly.

Use Cases and Applications

The BAS-8 has wide applicability across healthcare settings:

• As a follow-up to the MMAS-8R, identifying behavioral fragility in those who report high adherence.
• In digital health platforms for real-time behavioral monitoring.
• Within RTM (Remote Therapeutic Monitoring) protocols.
• As a clinical decision support tool in primary care, pharmacy, and behavioral coaching environments.

It is particularly powerful in populations prone to hidden or situational non-adherence, such as those managing polypharmacy, mental health disorders, or chronic illness under socio-economic strain.

The BAS-8 is not a replacement for existing adherence measures. It is a new dimension. One that asks not just if patients are adherent, but how stable that adherence really is. In doing so, it offers clinicians, researchers, and digital health innovators a behavioral compass to guide more personalized and proactive interventions.

 The BAS-8™ is the intellectual property of Philip Morisky and is exclusively distributed through Adherence. Unauthorized use, reproduction, or distribution of the BAS-8 is strictly prohibited.