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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 2, March/April 2019
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AFRICA
In contrast to the reverse-coded ACTS burdens, the highest
score on the ACTS benefits (scale from 1 to 5) indicates that the
patient is extremely satisfied with the treatment administered.
The ACTS burdens and the benefits scores are obtained after
summing up the scores from the 12 and three items, respectively.
The range of the former is 12–60 and the latter 3–15.
Results of a cross-cultural validation revealed that the item-
level and scale-level psychometric criteria were successfully
met by both the ACTS burdens and ACTS benefits. There
were some slight doubts with regard to the Dutch version of
the scales as the reliability criteria had not been met (
α=
0.72,
test–retest intra-class correlation
=
0.79). Aggregate endorsement
frequencies and skewness assessment conducted at an item level
indicated that the reduction of response options from five to four
might result in an improvement in response scales.
29,30
The Duke Anticoagulation Satisfaction Scale (DASS)
includes 25 items evaluating the positive and negative effects of
anticoagulation: limitations (e.g. limitations on physical activities
that might cause bleeding, or restrictions connected with diet),
hassles and burdens (e.g. daily and occasional hassles such as
remembering to take the medicine and waiting to have blood
tests done, respectively), and positive psychological impacts
(e.g. reassurance stemming from anticoagulation treatment
administration). Answers are given using a seven-item Likert scale.
The psychometric evaluation showed high Cronbach’s alpha
coefficients: 0.88 for the overall DASS summary score, 0.78
for the positive-impact sub-scale, 0.91 for the negative-impact
sub-scale, 0.87 for the limitations sub-scale, and 0.88 for the
hassles sub-scale. The questionnaire has been extensively used
with patients with AF or other diseases requiring anticoagulant
treatment.
31-35
It has been translated into Brazilian Portuguese,
and the cultural validation demonstrated very good psychometric
properties (Cronbach’s
α =
0.79).
36
In some studies, the Duke questionnaire was used as a
quality-of-life measure, and the authors demonstrated that
dissatisfaction with anticoagulant treatment contributed to lower
adherence, worse INR control and worse clinical outcomes. The
DASS scale is useful in identifying reasons for dissatisfaction
with treatment, and in planning and implementing interventions
to reduce this dissatisfaction.
37,38
The Adherence Barriers Questionnaire (ABQ) comprises
14 items evaluating three groups of factors associated with
non-adherence to treatment: intentional factors, unintentional
factors, and medication- and healthcare system-related barriers
to adherence. All answers are provided using a four-item Likert
scale. The authors validated the questionnaire with a group
of AF patients, demonstrating the very good psychometric
properties of this instrument (Cronbach’s
α
=
0.820). The
structure of the questionnaire makes it suitable for measuring
adherence in other diseases.
The Perception of Anticoagulation Treatment Questionnaire
(PACT-Q) was developed for evaluating patients’ expectations
of and satisfaction with anticoagulant therapy. The original
version of the questionnaire comprises 27 items. The PACT-1
section includes seven items evaluating the patients’ expectations
with regard to the prescribed anticoagulant treatment and is
completed before the treatment starts. The PACT-2 section
evaluates three dimensions: convenience of treatment (11 items),
burden of disease and treatment (two items), and satisfaction
(seven items). Answers are given using a five-item Likert scale.
The questionnaire was developed simultaneously in American
English, French and Dutch, and subsequently translated into 11
other languages, including Polish.
39
Content validity of DASS and
PACT-Q was good, as the scales included dimensions regarded
as important by the patients studied: satisfaction (DASS) and
treatment satisfaction (PACT-Q), hassles, limitations, burdens
(DASS), convenience (PACT-Q) and expectations (PACT-Q).
Adherence measures applicable to HF
One important dimension of HF treatment and care, besides
medication, is lifestyle modification, with the focus placed on
regular follow ups, restricting fluid and salt intake, and daily
weighing. With such treatment plans, measurements are required
not only of pharmaceutical adherence, but also of the self-care
capabilities of HF patients. Available publications point to
questionnaires assessing self-care opportunities, lifestyle changes
and pharmacological treatment. The most commonly used
questionnaires include the following.
The Self-Care of HF Index (SCHFI, pronounced ‘skiffy’),
which was originally named the Self‑Management of Heart
Failure Scale. Its 2004 version comprised 15 items, grouped into
three domains, with a ‘total self-care score’ optionally calculated
for the whole questionnaire. Over the years, the questionnaire
underwent several modifications. The current version includes
22 items in the following domains: maintenance (10 items),
management (six items) and confidence (six items), and the
author provides both the questionnaire and instructions for the
use of each of the three domains separately on her website. The
total score ranges from 0 to 100, with higher scores denoting
better adherence. The questionnaire has been translated into
a number of languages: Chinese, Italian, Spanish, German,
Portuguese, Japanese, French, Slovak and Dutch. Adaptation
studies showed that the instrument has good or very good
psychometric properties in all three domains, making it useful
in practice.
40
The European Heart Failure Self-Care Behaviour Scale
(EHFScB) was developed for measuring self-care capabilities in
terms of adherence to dietary recommendations, pharmaceutical
adherence, monitoring and identifying symptoms of
exacerbation, and care-seeking behaviour in HF. It was based on
Orem’s theoretical framework of self-care. Answers are provided
using a five-item scale, from ‘totally agree’ to ‘totally disagree’.
Two versions of the questionnaire are available, a nine- and a
12-item one. Scores on the EHFScB-9 range from 9 to 45 and the
lower the score, the better the self-care.
The internal consistency of EHFScB was 0.77 (0.71–0.85).
Psychometric properties and the content of individual items
were subjected to factor analyses and critical evaluation, after
which further analysis of EHFScB-9 was conducted. With
regard to EHFScB-9 overall, the reliability estimates were 0.80,
which is acceptable, whereas Cronbach’s
α
ranged between 0.68
and 0.87, depending on the country.
41,42
The instrument has
successfully passed validation and psychometric evaluation in
many populations and cultures, and has undergone multiple
translations and adaptations, including one into Polish.
43
The Medication Adherence Report Scale (MARS) is a
self-reported questionnaire used for evaluating adherence to
treatment in the case of chronic disease. The questionnaire
has been used in patients with COPD, asthma, chronic cancer