The interpretation of the two components was different (however, very
close) from the previously domains of interest (Belief, Barrier, and
Behavior) identified by the research team. In designing the AAMQ-13, all
potential items were stemmed from these three domains. The factor
analysis suggested the presence of two factors, intrestingly, all of the
‘Barrier’ domain items loaded strongly on component one, and all of the
‘Behavior’ domain items loaded strongly on component two, while the
‘Belief’ domain items (n= 3) were found to be distributed between the
two components (Table V). A person’s behavior is determined by his/her
intention to perform a behavior as stated in the Theory of Reasoned
Action. The person’s intention to perform a behavior is influenced by
the person’s attitude toward that behavior and the environmental
surroundings (40). This would highly explain why the last domain
(Beliefs) did not show as a separate component in factor analysis. As
beliefs cause barrier and lead to behavior; as a consequence, the
AAMQ-13 picks the endpoints. Therefore, we decided to extrapolate the
factor analysis results and conclude that the AAMQ-13 is not only able
to identify non-adherence patients and classify their adherence level
(poor, moderate, good, and excellent adherence), but it can also give
adequate information about the patterns of non-adherence (intentional or
unintentional non-adherence). This can be achieved by comparing the
total score of the five Behavior items (items number 3, 4, 5, 6, and 7)
which represent intentional non-adherence and the total score of the
five Barrier items (items number 8, 9, 10, 11, and 12) which represent
unintentional non-adherence.
The AAMQ-13 has a high sensitivity (0.85) and specificity (0.95) which
makes it a good candidate to assess asthmatic patient adherence to
medications. The sensitivity of the most commonly used published
questionnaires approximately ranged from 0.63 in the PIAQ to 0.848 in
the TAI (when the cut off of TAI score was 45) (15,41). As for
specificity ranged from 0.226 in the TAI, to 1.0 in the BMQ (for the
regimen screen part in the questionnaire) and 0.91 in the PIAQ
(13,15,41).
Methods used to assess the criterion validity of each questionnaire
varied widely from one questionnaire to another; some questionnaires
used subjective method (e.g. therapist report) such as the DAI, while
other questionnaires chose an objective method (e.g. the medication
event monitoring system (MEMS)) such as the BMQ and the BARS (11,13,16).
The AAMQ-13 was validated using both methods.
This study comes with few limitations; due to the coronavirus pandemic
and public quarantine that happened in March 2020 in the country,
interviewing patients was impossible in phase four (n= 213) and we were
not able to meet them face-to-face. Thus, in order to complete the
study, we decided to conduct the last phase of the study on an online
platform. Yet, the online procedure followed gave the needed results to
answer the main aims of the study. Furthermore, the AAMQ-13 has been
studied in the Arabic population and would need validation in an
English-speaking population.