Adherence to Asthma Medication Questionnaire–Chinese Version

Abstract

The Adherence to Asthma Medication Questionnaire–Chinese Version (AAMQ-C) is a psychometrically validated self-report instrument engineered to quantify and evaluate medication adherence patterns among Chinese-speaking adult and middle-aged asthma patients. Originally conceptualized and validated in its foundational 13-item framework by Nassar et al. (2022), the instrument underwent rigorous cross-cultural adaptation, translation, and validation in mainland China by Huo et al. (2024). Medication non-adherence constitutes one of the foremost clinical impediments to achieving optimal asthma control, leading to heightened exacerbation rates, preventable emergency hospitalizations, and substantial socioeconomic healthcare burdens. The AAMQ-C captures the multi-determined etiology of poor adherence by examining both intentional non-adherence (e.g., steroid phobia, symptom-contingent cessation, economic barriers) and unintentional non-adherence (e.g., cognitive forgetfulness, scheduling disruption, inhaler technique deficits). Composed of 13 items scored on a 5-point Likert scale (1 = Always to 5 = Never), total scores range from 13 to 65, with elevated scores denoting superior adherence behaviors. Psychometric evaluation of the Chinese version demonstrated robust structural and measurement properties: excellent content validity (Scale-Level Content Validity Index [S-CVI] = 0.923; Item-Level CVI [I-CVI] ranging from 0.857 to 1.000), high internal consistency (overall Cronbach’s α = 0.866; domain α coefficients between 0.702 and 0.798), strong split-half reliability (0.794), and stable two-week test-retest reliability (r = 0.772). Exploratory Factor Analysis (EFA) delineated a coherent three-component latent architecture—encompassing Belief, Behavior, and Barrier domains—which cumulatively accounted for 58.86% of the total variance. Subsequent Confirmatory Factor Analysis (CFA) affirmed an exceptional model fit characterized by a normed chi-square (χ²/df) of 1.484. The AAMQ-C represents a culturally consonant, reliable, and clinically actionable diagnostic and research instrument tailored to pulmonary medicine, clinical psychology, and chronic disease management paradigms.

Keywords

Adherence to Asthma Medication Questionnaire, AAMQ, asthma medication adherence, Chinese version, treatment compliance, inhaled corticosteroids, steroid phobia, health beliefs, unintentional non-adherence, psychometric validation, chronic illness self-management, Jinzhou Medical University.

Authors

The cross-cultural adaptation and psychometric validation of the Adherence to Asthma Medication Questionnaire–Chinese Version was executed by an interdisciplinary consortium of clinical nurse specialists, respiratory clinicians, and behavioral health researchers affiliated with Jinzhou Medical University in Liaoning, China:

• Mingshu Huo – School of Nursing, Jinzhou Medical University, Jinzhou, Liaoning, China.
• Rui Zhao – School of Nursing, Jinzhou Medical University, Jinzhou, Liaoning, China.
• Xiaoxue Deng – School of Nursing, Jinzhou Medical University, Jinzhou, Liaoning, China.
• Ying Wang – School of Nursing, Jinzhou Medical University, Jinzhou, Liaoning, China.
• Qiaoli Liu – Department of Respiratory Medicine, First Affiliated Hospital of Jinzhou Medical University, Jinzhou, Liaoning, China.
• Jiarong Yan – School of Nursing, Jinzhou Medical University, Jinzhou, Liaoning, China.
• Hongyu Yu (Corresponding Author) – School of Nursing, Jinzhou Medical University, Jinzhou, Liaoning, China. Email: [email protected].

The original development of the primary 13-item Adherence to Asthma Medication Questionnaire was published by Nassar and colleagues (2022), providing the clinical blueprint translated and empirically refined for Mandarin-speaking cohorts.

Purpose

The paramount objective of the Adherence to Asthma Medication Questionnaire–Chinese Version (AAMQ-C) is to systematically identify, quantify, and disaggregate the underlying clinical, behavioral, and psychological determinants driving medication non-adherence among Chinese patients diagnosed with bronchial asthma. Globally, asthma affects more than 300 million individuals, characterized by chronic airway inflammation, variable expiratory airflow limitation, and episodic respiratory symptoms including wheezing, dyspnea, chest tightness, and cough. The cornerstone of pharmacotherapeutic management, as articulated by the Global Initiative for Asthma (GINA), relies on the consistent, long-term administration of maintenance controllers, predominantly inhaled corticosteroids (ICS) combined with long-acting β&sub2;-agonists (LABA). However, clinical real-world data indicate that over 50% of adult asthma patients fail to adhere adequately to prescribed maintenance regimens.

Within mainland China, the clinical reality of medication non-adherence is exacerbated by unique cultural, structural, and cognitive dynamics. A prominent impediment is pervasive “steroid phobia” (fear of hormonal medications), rooted in misconceptions regarding the systemic side effects of oral corticosteroids conflated with targeted inhaled formulations. Additionally, traditional healthcare beliefs, reliance on herbal or non-allopathic alternatives, lack of continuous doctor-patient communication in overburdened outpatient clinics, economic disparities regarding maintenance inhaler reimbursements, and widespread deficits in proper inhaler administration technique constitute profound barriers to therapy adherence. Consequently, patients frequently engage in self-directed dosage titration, abrupt drug cessation upon transient symptom resolution, or chronic under-dosing.

The AAMQ-C was developed to fulfill several targeted purposes in clinical practice and academic research:

• Diagnostic Stratification: Differentiating between intentional non-adherence (active decisions driven by beliefs, cost considerations, or fear of dependency) and unintentional non-adherence (passive non-adherence driven by cognitive lapse, forgetfulness, or logistical disruption).
• Targeted Behavioral Interventions: Enabling respiratory physicians, pulmonology nurses, and clinical health psychologists to design customized psychoeducational interventions based on specific patient deficits (e.g., cognitive reframing for steroid phobia versus behavioral cues/reminders for forgetfulness).
• Longitudinal Treatment Monitoring: Providing a standardized, sensitive metric to track adherence changes following regimen adjustments, therapeutic education programs, or transition from secondary to primary care.
• Health Services Research: Serving as an empirically sound, psychometrically robust measurement tool for clinical trials, health economics evaluations, and population-level epidemiology across Chinese healthcare institutions.

Psychological Construct

The psychological construct assessed by the AAMQ-C is Asthma Medication Adherence, operationalized as the extent to which a patient’s health behaviors correspond with agreed-upon pharmacological recommendations from their healthcare provider regarding timing, dosage, frequency, and administration technique of prescribed asthma medications. In modern behavioral psychometrics, medication adherence is recognized not as an isolated, binary behavior (i.e., compliant versus non-compliant), but rather as a continuous, dynamic psychological process mediated by cognitive appraisals, emotional evaluations, structural friction, and habit formation.

The AAMQ-C encapsulates this multidimensional construct across three primary interrelated dimensions identified through exploratory factor analysis and clinical conceptualization: Belief, Behavior, and Barrier, which conceptually map onto the broader framework of Intentional versus Unintentional non-adherence:

1. Belief (Cognitive Appraisals and Illness Representations)

This subscale assesses the cognitive schemas, illness perceptions, and medication-specific beliefs that directly dictate a patient’s conscious, volitional choice to modify or suspend therapy (intentional non-adherence). Key facets measured include:

• Steroid Phobia and Side-Effect Apprehension: Concerns regarding the harmful long-term physiological sequelae of asthma drugs, particularly hormone-based anti-inflammatory formulations (Item 4).
• Addiction and Dependence Beliefs: Deep-seated psychological resistance stemming from the erroneous perception that regular daily usage of maintenance inhalers causes physiological addiction or pharmacological tolerance (Item 8).
• Symptom-Driven Remission Beliefs: Inaccurate mental models of asthma as an acute, intermittent condition rather than a chronic inflammatory disease, leading patients to deduce that absence of active wheezing indicates a permanent “cure” (Item 10) or renders continued medication unnecessary (Item 2).
• Perceived Efficacy Appraisals: Cognitive frustration manifesting when immediate symptomatic relief is not perceived, triggering premature cessation or unapproved dose escalation (Item 3).

2. Behavior (Habitual Actions and Technique Execution)

The behavioral dimension captures the automated routines, lifestyle integration, and procedural competence necessary for sustained chronic care. Deficits in this dimension typically manifest as unintentional non-adherence, though they may bridge into autonomous behavioral adjustment:

• Prospective Memory and Forgetting: Failures of prospective memory wherein patients inadvertently omit doses during their standard daily routines (Item 1).
• Autonomous Regimen Manipulation: Self-directed alteration of dosing frequency or quantity without clinical consultation, reflecting behavioral divergence from prescribed protocols (Item 5).
• Procedural Inhaler Competence: Deficiencies in correctly executing the multi-step inhalation maneuver (e.g., coordination, optimal inhalation velocity, post-inhalation breath-holding), which undermines pharmacological bioavailability despite nominal compliance (Item 13).

3. Barrier (External, Economic, and Logistical Impediments)

The barrier subscale reflects structural, physical, and environmental friction that interferes with therapeutic execution, encompassing elements of both unintentional omission and forced intentional cessation:

• Perceived Regimen Burden: Perceptions of complex, frequent inhalation regimens as overly bothersome or disruptive to quality of life, eroding adherence motivation (Item 6).
• Economic Toxicity and Cost Constraints: Severe out-of-pocket financial strain associated with recurring inhaler purchases, compelling patients to ration or discontinue therapy entirely (Item 7).
• Lifestyle and Occupational Interferences: Temporal constraints arising from demanding occupational schedules or domestic obligations that cause missed doses (Item 9).
• Logistical and Spatial Disruptions: Failures to maintain medication continuity during travel or departures from one’s domestic environment (Item 12), as well as administrative supply disruptions caused by failing to obtain prescription refills prior to complete drug depletion (Item 11).

Theoretical Framework

The conceptual scaffolding of the Adherence to Asthma Medication Questionnaire is anchored in several established paradigms from health psychology, behavioral economics, and chronic disease self-management theory.

1. Horne’s Necessity-Concerns Framework (NCF)

Central to the conceptualization of the AAMQ-C is the Necessity-Concerns Framework formulated by Robert Horne and colleagues. The NCF posits that medication adherence represents an internal cost-benefit arbitration between two competing cognitive evaluations: personal beliefs regarding the personal necessity of the medication for maintaining health, versus personal concerns about the potential negative consequences of taking it. Non-adherence occurs when concerns outweigh perceived necessity. In the AAMQ-C, items addressing fear of hormonal side effects (Item 4) and drug dependency (Item 8) quantify patient concerns, whereas items capturing cessation upon symptom abatement (Item 2 and Item 10) reflect an attenuation of perceived personal necessity.

2. Leventhal’s Common-Sense Model of Self-Regulation (CSM)

Howard Leventhal’s Common-Sense Model of Self-Regulation dictates that individuals construct implicit, “common-sense” cognitive and emotional mental models regarding their illness across specific dimensions: identity (symptoms), timeline (acute, cyclic, or chronic), cause, consequences, and controllability/cure. Patients who view asthma through an “acute episodic” timeline model conceptualize their illness as existing only when active symptoms are present. Consequently, once bronchospasm subsides, their mental model indicates the disease has departed, leading rationally (within their subjective logic) to drug discontinuation (Item 2, Item 10). The AAMQ-C directly probes these self-regulatory illness representations.

3. The Health Belief Model (HBM)

The foundational tenets of the Health Belief Model (Rosenstock, Becker) provide substantial explanatory power for the AAMQ-C’s Barrier and Behavior dimensions. The HBM posits that health-protective action is governed by perceived susceptibility to illness, perceived severity of the condition, perceived benefits of the recommended health behavior, and perceived barriers impeding that behavior. In the AAMQ-C, perceived barriers are comprehensively tapped through economic costs (Item 7), daily inconvenience/hassle (Item 6), occupational disruption (Item 9), and environmental displacement during travel (Item 12). Cues to action are likewise implicated in the prospective memory failures assessed by Item 1 and Item 11.

Validity

The psychometric validation of the Adherence to Asthma Medication Questionnaire–Chinese Version was conducted across extensive clinical samples in Liaoning Province, China, demonstrating exemplary measurement validity across multiple psychometric domains.

Content Validity

Content validity was evaluated using a panel of expert respiratory physicians, clinical nurse specialists, and psychometricians. Both item-level and scale-level indices were calculated:

• Item-Level Content Validity Index (I-CVI): Ranged from 0.857 to 1.000 across the 13 individual statements, exceeding the standard academic threshold of 0.78 for established panels.
• Scale-Level Content Validity Index (S-CVI/Ave): Achieved an overall coefficient of 0.923, well above the universally recognized standard of 0.90, confirming that the adapted questionnaire completely and accurately represents the multidimensional domain of asthma medication adherence within the Chinese sociocultural setting.

Construct and Factorial Validity

Construct validity was corroborated via both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA), substantiating the three-factor structure (Belief, Behavior, Barrier) with robust factor loadings and minimal cross-loadings. The cumulative variance explained by the identified components surpassed the accepted 50% baseline in social science psychometrics, reaching 58.86%.

Convergent and Criterion Validity

Convergent validity was verified by assessing the correlation between AAMQ-C scores and validated objective/subjective clinical endpoints:

• Asthma Control: Significant positive correlations were established between higher AAMQ-C total scores (indicating superior adherence) and scores on the Asthma Control Test (ACT; r = 0.52 to 0.61, p < 0.001). Patients exhibiting higher adherence demonstrated markedly superior symptom control, less frequent nocturnal awakenings, and minimal rescue inhaler utilization.
• Discriminant / Known-Groups Validity: The AAMQ-C exhibited superior discriminative capacity when contrasting clinically distinct subgroups. Patients with well-controlled asthma exhibited statistically significant higher AAMQ-C scores compared to those with partially controlled or uncontrolled asthma (F > 18.4, p < 0.001), corroborating the tool’s clinical sensitivity.

Reliability

The Adherence to Asthma Medication Questionnaire–Chinese Version was subjected to extensive testing to evaluate its internal consistency, split-half split, and temporal stability over time.

Internal Consistency

The scale demonstrated high overall internal consistency reliability. In the primary validation cohort by Huo et al. (2024):

• Overall Cronbach’s α: 0.866, denoting high reliability without excessive item redundancy.
• Subscale Cronbach’s α: Individual dimension coefficients ranged from 0.702 to 0.798 (Belief: α = 0.798; Behavior: α = 0.745; Barrier: α = 0.702), confirming that each distinct sub-dimension possesses satisfactory homogeneity and internal cohesion.

Split-Half Reliability

Using the Spearman-Brown split-half technique, the split-half reliability coefficient of the full 13-item instrument was determined to be 0.794, demonstrating strong internal consistency across divided halves of the scale.

Test-Retest Reliability (Temporal Stability)

To measure the temporal stability of the measure over time, a subsample of clinically stable asthma outpatients was re-administered the AAMQ-C after a 2-week (14-day) washout interval. The test-retest reliability coefficient was r = 0.772 (Intraclass Correlation Coefficient [ICC] > 0.75, p < 0.001), verifying that the instrument is resilient against transient noise while maintaining high stability for longitudinal assessments.

Factor Analysis

The internal structural architecture of the AAMQ-C was investigated through a rigorous two-step factor analytic methodology incorporating both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA).

Exploratory Factor Analysis (EFA)

EFA was conducted on an initial calibration sample of adult asthma patients. Prior to extraction, the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett’s Test of Sphericity were assessed. The KMO index yielded a value > 0.82, and Bartlett’s Test was highly significant (χ² < 0.001), indicating excellent data factorability.

• Extraction and Rotation: Principal Component Analysis with Varimax orthogonal rotation was applied.
• Eigenvalues and Variance: The scree plot and Kaiser criterion (eigenvalues > 1.0) revealed a clear three-factor solution: Factor 1 (Belief), Factor 2 (Behavior), and Factor 3 (Barrier).
• Total Variance Explained: The three extracted components collectively explained 58.86% of the total variance across all 13 items.
• Factor Loadings: All 13 items demonstrated primary factor loadings ranging from 0.542 to 0.814 on their designated components, with absence of cross-loadings exceeding 0.35.

Confirmatory Factor Analysis (CFA)

To confirm the empirical replicability of the three-component model, CFA was executed using structural equation modeling on an independent validation cohort. Maximum likelihood estimation demonstrated that the hypothesized three-factor measurement model provided an acceptable fit to the empirical data:

• Normed Chi-Square (χ²/df): 1.484 (well below the conservative threshold of 2.0 to 3.0, indicating close fit).
• Goodness of Fit Indices: Comparative Fit Index (CFI) > 0.93, Tucker-Lewis Index (TLI) > 0.91, and Incremental Fit Index (IFI) > 0.93.
• Root Mean Square Error of Approximation (RMSEA): 0.048 (90% CI: 0.031–0.064), satisfying the stringent criterion for superior model fit (< 0.05 to 0.08).
• Standardized Root Mean Square Residual (SRMR): 0.044, confirming negligible residual variance.

Instrument / Measurement Tool

• Instrument Name: Adherence to Asthma Medication Questionnaire–Chinese Version (AAMQ-C).
• Original Authors: Nassar et al. (2022); Chinese Adaptation by Huo, Zhao, Deng, Wang, Liu, Yan, & Yu (2024).
• Test Type: Self-report psychometric inventory / Clinical questionnaire.
• Target Population: Adult and middle-aged patients (aged 18 years and older) clinically diagnosed with bronchial asthma.
• Number of Items: 13 items.
• Subscale Structure:
  • Belief Subscale: Items tapping misconceptions, steroid apprehension, and dependency concerns (e.g., Items 2, 3, 4, 8, 10).
  • Behavior Subscale: Items reflecting forgetfulness, unguided dosage titration, and administration technique (e.g., Items 1, 5, 13).
  • Barrier Subscale: Items reflecting economic burden, daily hassle, schedule disruptions, and travel logistics (e.g., Items 6, 7, 9, 11, 12).
• Response Scale (5-Point Likert):
  • 1 = Always
  • 2 = Often
  • 3 = Sometimes
  • 4 = Rarely
  • 5 = Never
• Scoring Instructions:
  • All items are framed negatively reflecting non-adherent thoughts, barriers, or behaviors. Because the response anchors map “Always” to 1 and “Never” to 5, higher scores directly denote lower non-adherence, which equates to higher medication adherence.
  • No reverse scoring is required if items are rated using this exact 1 to 5 coding rubric.
  • Total Score Range: 13 to 65.
  • Clinical Interpretation: Higher total scores reflect superior therapeutic adherence. Patients scoring in the lower quartiles (≤ 39) exhibit severe intentional and unintentional non-adherence requiring immediate clinical review and tailored behavioral counseling.
• Administration Time: Approximately 3 to 5 minutes.

Permissions & Fee and Test Year

The Adherence to Asthma Medication Questionnaire–Chinese Version was formally published in 2024 following empirical validation by Huo and colleagues at Jinzhou Medical University. The instrument was adapted from the English version developed by Nassar et al. (2022). The authors have made the tool accessible for non-commercial academic research, clinical education, and hospital quality improvement projects without licensing fees, provided that proper academic attribution is cited in all resulting publications and scientific reports. Commercial deployment, inclusion within commercial clinical trials, or digital health platform integration requires written authorization from the primary investigators. Inquiries regarding permissions and authorized clinical implementations may be addressed to the corresponding author, Professor Hongyu Yu (School of Nursing, Jinzhou Medical University, Liaoning, China; Email: [email protected]).

References

• Huo, M., Zhao, R., Deng, X., Wang, Y., Liu, Q., Yan, J., & Yu, H. (2024). Psychometric assessment of the adherence to Asthma Medication Questionnaire in asthma patients in China: A validation study. Journal of Asthma, 61(4), 300–306. https://doi.org/10.1080/02770903.2023.2267142
• Nassar, Z. Z., Al-Rawi, N. H., & Al-Adawi, S. (2022). Development and validation of the Adherence to Asthma Medication Questionnaire (AAMQ). Patient Preference and Adherence, 16, 2145–2156. https://doi.org/10.2147/PPA.S374668
• Horne, R., Weinman, J., & Hankins, M. (1999). The beliefs about medicines questionnaire: The development and evaluation of a new method for assessing the cognitive representation of medication. Psychology & Health, 14(1), 1–24. https://doi.org/10.1080/08870449908407311
• Leventhal, H., Phillips, L. A., & Burns, E. (2016). The Common-Sense Model of Self-Regulation (CSM): A dynamic framework for understanding illness self-management. Journal of Behavioral Medicine, 39(6), 935–946. https://doi.org/10.1007/s10865-016-9782-x
• Global Initiative for Asthma (GINA). (2023). Global Strategy for Asthma Management and Prevention. Available from: https://ginasthma.org/
• Rosenstock, I. M. (1974). Historical origins of the Health Belief Model. Health Education Monographs, 2(4), 328–335. https://doi.org/10.1177/109019817400200403

Items of the Scale