545383 research-article2014
CNRXXX10.1177/1054773814545383Clinical Nursing ResearchAlhalaiqa et al.
Article
Validity of Arabic Version of Beliefs About Medication Questionnaire
Clinical Nursing Research 1–17 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1054773814545383 cnr.sagepub.com
Fadwa Alhalaiqa, PhD, CNS, RN1, Rami Masa’Deh, PhD2, Abdul-Monim Batiha, PhD1, and Katherine Deane, BSc, PhD3
Abstract To assess the validity and reliability of the Arabic version of the Beliefs About Medication Questionnaire, a cross-sectional design was used and the data were collected from 605 patients with chronic diseases. The study was conducted between July 2013 and December 2013. The results showed that the Cronbach’s alpha coefficient (.71) was satisfactory. There was a significant strong positive correlation between test–retest for the same group subsample, with a correlation coefficient range of .45 to .78. There were no statistically significant differences between retest subgroups and remaining samples in the questionnaire subscales. The percentage of missing value was around 0.03, which confirmed the feasibility of the Arabic version of the questionnaire. These findings suggested that having a culturally acceptable, valid and reliable instrument to identify patients’ beliefs toward medication in Jordan will play an important role in tailoring appropriate intervention to enhance patient compliance with their prescribed medication.
1Faculty
of Nursing, Philadelphia University, Amman, Jordan of Nursing, Applied Science Private University, Amman, Jordan 3School of Nursing Sceinces, University of East Anglia, Norwich, UK 2Faculty
Corresponding Author: Fadwa Alhalaiqa, PhD, CNS, RN, Faculty of Nursing, Philadelphia University, Amman 19392, Jordan. Email: [email protected], [email protected]
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Keywords beliefs, medication, reliability, validity, compliance
Introduction Beliefs are playing an important role in patient health behaviors (Janz & Becker, 1984). This is supported by the development of a health belief model in 1950 (Rosenstock, 1974). The guidelines developed by the World Health Organization (WHO, 2003) and National Institute for Clinical Excellence (NICE) recommended health care professionals to explore patient’s concerns, attitudes, and beliefs toward medication as these were the most critical causes of nonadherence among chronic disease patients (Horne, Weinman, & Hankins, 1999; Morrison, Wertheimer, & Berger, 2000; Nunes et al., 2009). This exploration was the main aim of Western researchers, therefore they developed many instruments, one being the Beliefs About Medication Questionnaire (BMQ), developed by Horne et al. (1999). This current study aims to validate the Arabic version of the BMQ.
Background The prevention and management of chronic disease in Jordan is becoming an important issue for health care providers (HCPs). There is a high prevalence of chronic diseases in Jordan (e.g., hypertension and diabetes) together with their risk factors (e.g., obesity, overweight, cigarette smoking, high cholesterol level; Al-Nsour et al., 2012; Malkawi, 2012). By 2050, 3.5 million (50%) people in Jordan are expected to have diabetes mellitus, 3.7 million (53%) with hypertension, and 2.93 million (41%) with high cholesterol (Brown, et al., 2009). Thus, the burden of noncommunicable diseases in Jordan is increasing (Malkawi, 2012; Al-Nsour et al., 2012). In 2004, the direct and indirect costs of treating chronic diseases (e.g., diabetes, hypertension, obesity, and high cholesterol) in Jordan was 1.3 billion Jordanian dinars (equal to US$1.82 billion; Malkawi, 2012). In 2005, chronic diseases were considered to be responsible for more than 50% of deaths in Jordan (Ministry of Health [MOH], 2008). By 2030, two thirds of deaths in the Middle East region will be as a result of noncommunicable diseases (Brown et al., 2009). By 2020, the mortality rate in developing countries from ischemic heart diseases is expected to increase by 120% for women and 137% for men (Leeder, Raymond, Greenberg, Liu, & Esson, 2004). Although the treatment of chronic diseases by medication is well established, most of the patients do not adhere to taking their medication as their doctor has prescribed (Haynes, Ackloo,
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Sahota, & McDonald, 2008; WHO, 2003, 2009). WHO (2003) reported that medication adherence rates are around 50% for patients suffering from chronic diseases in developed countries. Nonadherence rates in developing countries are considered to be much higher, with Al-Qasem et al. (2011) estimating the nonadherence rate to be as high as 88% in the Middle East. Patients who doubt that their medicines will positively affect their health, and who are concerned about their body’s response to medication and its potentially negative side effects, are less likely to be compliant in taking their medicines than those who have positive beliefs and attitudes (Ajlouni, Khader, Batieha, Ajlouni, & El-Khateeb, 2008; Alhalaiqa, Deane, & Gray, 2013; Alhalaiqa, Deane, Nawafleh, Clark, & Gray, 2012; Horne et al., 1999). An adherence therapy intervention that explored patients’ attitudes and beliefs has improved hypertensive patients’ compliance to the taking of their medication but also had a positive effect on clinical markers of risk, that is, blood pressure (BP), thus reducing the patient’s risk of complications and mortality (Alhalaiqa et al., 2013; Alhalaiqa et al., 2012; Horne et al., 1999). So, by addressing patient’s attitudes and beliefs and improving regimen adherence, it is arguable that the burden of chronic diseases would be reduced (Alhalaiqa et al., 2012; Malkawi, 2012; WHO, 2003). One key goal of the national health system in Jordan is to prevent and control these long-term conditions by providing effective health services. The Jordan MOH, in cooperation with the Jordan Department of Statistics, the WHO, and the Centers for Disease Control and Prevention (CDC), established the Jordan Behavioral Risk Factor Surveillance Survey (BRFSS) to decrease the burden of chronic diseases. BRFSS is used to collect data on health risk behaviors, clinical preventive health practices, and health care access that are associated with leading causes of illness and death in Jordan (CDC, 2006). Unfortunately, the BRFSS does not measure a patient’s attitudes and beliefs toward medication, factors that are considered to be the corner stone in determining the patient’s level of adherence to their medication regimen, which is a crucial health behavior indicator that could prevent disease complications. There are many instruments available to explore patients’ beliefs toward medication (e.g., Hyperlipidemia: Attitudes and Beliefs in Treatment [HABIT]; Foley, Vasey, Berra, Alexander, & Markson, 2005), the Beliefs About Medication Compliance Scale (Bennett, Milgrom, Champion, & Huster, 1997; Riekert & Drotar, 2002). However, the most commonly used is the BMQ (Alhalaiqa et al., 2012; Perpiñá Tordera, Martínez Moragón, Belloch Fuster, Lloris Bayo, & Pellicer Císcar, 2009; Salgado et al., 2013). The specific BMQ is used to measure particular groups of patients and their beliefs regarding specific types of drugs. The general BMQ is used to analyze patients’ beliefs involving broader concepts (Horne et al., 1999).
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At present, there are no instruments that measure patients’ beliefs and attitudes toward their medications, which have been designed or adapted for Arabic culture and language. In addition, many Arabic researchers have asked to use the Arabic version of the BMQ, which had been used by Alhalaiqa et al. (2012). Therefore, the aim of this study was to validate the Arabic version of BMQ.
Method Study Design A cross-sectional survey design was used. The questionnaire survey was completed by people who are affected by one or more chronic diseases. After obtaining permission to use the BMQ from the developer of the original English version (Horne et al., 1999), translation of the BMQ into Arabic was done, based on an internationally accepted translation process (Brislin, 1970, 1986; Brislin, Lonner, & Throndike, 1973; WHO, 2013). An expert panel was selected to monitor the adaptation procedure of the BMQ. The main two steps of translation were forward and backward by two professional bilingual persons with medical backgrounds. One translator was a cardiologist and the other a nursing lecturer at Al-Hashmiah University. They independently translated the original English measures into Arabic, and then combined the translations from these two copies to create a single Arabic version. Another two bilingual translators did the backward translation. One translator was an English master’s student and the other one was a registered nurse with a master’s degree. A final English version of each measure was then sent to the original authors. There were no changes made to the back-translated version. All the authors were satisfied with the final English versions. To test clarity, comprehensiveness, appropriateness, and cultural relevance, the final version (the appendix) of the questionnaire was tested on 20 candidates (other than those who were included in the validation sample) before conducting the actual study. All participants were interviewed and encouraged to give comments on the measures. Minor revisions were made to the Arabic version of the instrument, based on the results of interviews, without any change to the conceptual meanings.
Participants and Setting The convenience sample procedure was used. The sample size was calculated by using a power equation to be 400 patients, based on the confidence interval of 1.96, margin of error of 5% and 45% the prevalence of chronic diseases in Jordan. The drop-out rate was calculated and considered to have a sample
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size of 500 patients. The inclusion criteria were a chronic disease patient aged 18 years or above, who was taking regular medications, able to read and write Arabic, had no obvious cognitive deficit, and had follow-up appointments at an outpatient clinic. The aim of the research was to cover most areas in Jordan. As there are three main geographical regions in the country (north, middle, and south), we selected the hospitals which provide health care service for most Jordanians. Therefore, the study was carried out in three multidisciplinary centers (Jordan MOH and private hospitals).
Ethical Considerations The study was approved by all hospitals from which the participants were recruited. Informed consent was gained from all participants before starting the study. Patient privacy and confidentiality were maintained. We explained to participants that they have the right to freely participate in the study and can withdraw at any time without giving any reasons and their withdrawal would not affect the health services provided to them.
Data Collection Methods Self-reported questionnaires were used to collect the data. The general version BMQ12 which is designed to measure positives (e.g., benefits) and negative beliefs and attitudes (e.g., over use) was employed (Horne et al., 1999). It has four sections with a total of 17 items. Each question is rated on a 5-point Likert-type scale, with a score of 5 indicating strongly agree, to measure the following: 1. Harm (GH): the harmful characteristics of medication (four questions). 2. Overuse (GO): (overprescribing) the way of prescribing medications by (HCPs; four questions). 3. General sensitivity (GS): sensitivity of the patients to adverse events from medications (five questions). 4. General benefit (GB): the positive properties of medication (four questions). Sociodemographic factors including age, gender, educational, marital, employment status, comorbidity (presence of other diseases), duration of the disease, BP, and blood sugar (BS) were measured through a questionnaire that was developed for the purpose of this specific study.
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Recruitment Procedure Research assistants (RAs) were trained to handle the questionnaire in the same manner (to reduce the risk of assessment bias). Participants were recruited by reviewing patients’ health records in clinics by RAs. An information sheet was given to all participants who met the inclusion criteria. After signifying their agreement, all participants were interviewed by the RAs and completed the Arabic BMQ version and demographic questionnaire (the average time needed by each participant to fill in the questionnaires was 15 min). After 2 weeks, the BMQ was administered for the second time in a subsample (n = 132) of patients by the RAs.
Data Analysis Descriptive statistics were used to describe the sample; the quantitative variables were described by using mean and standard deviation (SD); qualitative variables were described using frequency and percentages. The questionnaire’s internal consistency was assessed by measuring Cronbach’s alpha coefficient. Values equal to or greater than .70 were considered satisfactory (Bland & Altman, 1996). The test–retest reliability was done by using Pearson’s product–moment correlation coefficient. The Mann–Whitney U test was used to determine whether there are differences between the retest subgroup and the remaining study sample. The feasibility of the Arabic version of the BMQ was determined; based on the percentage of missing responses for each item. Floor and ceiling effects of each score of the BMQ were calculated as the percentage of subjects achieving the lowest and highest possible score. Additional analysis, including bivariate correlations, was used to examine the associations of BMQ subscale scores with the variables of interest (age, comorbidity, and duration of disease) as well as to identify if there are any relationships between BMQ subscale and these demographic variables.
Results Participants’ Characteristics The study was conducted between July 2013 and December 2013. Data were collected from 605 patients. Their demographic data showed that their mean age was around 55.9 years (SD = 12.5). The majority of participants were Jordanian (n = 559), more than 50% of them were male (53%, n = 321) and 51% were not working at the time of conducting the study (n = 314). More than three quarters of the participants were educated (at least they finished
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Alhalaiqa et al. Table 1. Demographical Characteristics.
Age Level of income Gender Male Female Nationality Jordanian Other Education Educateda Noneducated Marital status Married Single Widowed Insurance Insured Noninsured Occupation Working Not working Retired aEducated
Minimum
Maximum
M
19.00 0.00
86.00 1,500.00
55.9 (12.6) 396.7 (182.1)
Frequency
%
321 284
53.1 46.9
559 46
92.4 7.6
514 91
85 15
526 26 53
86.9 4.3 8.8
480 125
79.3 20.7
139 314 152
23 51.9 25.1
means has at least finished the secondary school.
the secondary school; 85%, n = 514), married (87%, n = 526), had health insurance (79%, n = 480; see Table 1). Table 2 shows the clinical characteristics of the participants; around 42% of them having comorbidity (two or more types of disease). The most common diagnoses were hypertension and diabetes (52% and 39%, respectively) with disease duration of more than 5 years (around 56%). The participants’ mean systolic blood pressure (SBP) was 142 mmHg (SD = 18.8), diastolic (DBP) was 92 mmHg (SD = 11.2), and their BS was 174 mg/dl (SD = 79.9). Regarding the BMQ subscales, participants in this study believed that the medication is over prescribed and over used by HCPs (M = 15.1; SD = 2.9); intrinsically harmful (M = 14.2; SD = 3.4); and they were very sensitive to its
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Table 2. Clinical Characteristics. Frequency
%
349 216 40
57.7 35.7 6.6
312 235 14 14 20 10
51.6 38.8 2.3 2.3 3.3 1.7
264 179 159
43.6 29.6 26.3
Comorbidity one disease Two types of diseases More than two types of diseases Medical diagnosis Hypertension Diabetes Chronic renal failure Respiratory Cardiovascular Others Disease duration (years) 1-5 More than 5 to 10 More than 10 SBP, mmHg DBP, mmHg Blood sugar level, mg/dl GH GO GB GS
Minimum
Maximum
M (SD)
90.00 50.00 69.00 7 8 8 7
195.00 150.00 500.00 52 45 20 54
142.2 (18.8) 92.1 (11.2) 174.4 (79.9) 14.2 (3.4) 15.1 (2.9) 15.3 (2.6) 17.1 (2.5)
Note. SBP = systolic blood pressure; DBP = diastolic blood pressure; GH = harm; GO = overuse; GB = general benefit; GS = general sensitivity.
adverse events (M = 17.1; SD = 2.5). However, they believed that there were some positive properties for the medication (M = 15.3; SD = 2.6).
Reliability of BMQ According to George and Mallery (2003) and Kline et al. (2002), the questionnaire has good internal consistency, with a Cronbach’s alpha coefficient reported between .7 ≤ α < .9. In the current study, the Cronbach’s alpha coefficient for the total questionnaire was .71. However, the BMQ subscales had acceptable reliability for GS and GB (Cronbach’s α scores were .65 and .55, respectively), while the negative beliefs and statements about GH and GO subscales had poor reliability (Cronbach’s α scores were .35 and .3, respectively).
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Table 3. Pearson’s Product–Moment Correlation Between BMQ Items at Baseline and After 2 Weeks. BMQ items
Pearson’s correlation (r)
p value
.456** .724** .778** .788**
.000 .000 .000 .000
GH GO GB GS
Note. BMQ = Beliefs About Medication Questionnaire; GH = harm; GO = overuse; GB = general benefit; GS = general sensitivity. **Correlation is significant at the .01 level (two-tailed).
Table 4. Mann–Whitney U Test Statistics.
Mann–Whitney U z p value
GO
GH
GB
GS
37,956.000 −1.180 .238
25,785.000 −6.658 .000
28,045.000 −5.794 .000
37,850.500 −1.279 .201
Note. Grouping variable: group. GO = overuse; GH = harm; GB = general benefit; GS = general sensitivity.
Test–Retest Reliability As shown in Table 3, scores were reliable over an interval of 2 weeks. Pearson’s product–moment correlation coefficient was employed for the same subgroups after 2 weeks and it ranged from .45 to .78 for the entire sample. There was a significant, strong positive correlation between the BMQ items at Time 1 and Time 2.
Differences in BMQ Subscales There were no statistically significant differences between the two groups (retest subgroup and remaining sample) in the BMQ subscales; GO and GS (see Table 4). However, the differences between groups in terms of GB and GH of the BMQ subscales were significant (p = .000).
The Feasibility of BMQ The Arabic version of the BMQ is feasible because the percentage of missing value for each item was only around 0.03.
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The Ceiling and Floor Effects The distribution of participants’ responses, evaluated by ceiling and floor effects, showed appropriate proportions and good discrimination of BMQ items.
Additional Analysis The relationship between age and BMQ subscales was investigated by using the bivariate correlation. The results showed that there was a small positive correlation between age and perceived general medication overuse and benefit (r = .23, n = 604, p = .000; r = .1, n = 604, p = .010), respectively. An increase of the age of the patient was correlated with an increase in his or her beliefs about overuse of medication as prescribed by their doctor and the benefit of the medication to the patient. The relationship between comorbidity and BMQ subscales was tested. The results indicate that for a patient who had more than one type of disease, his or her beliefs about the overuse of the medication prescribed by doctors, and that patient’s sensitivity to medication, were increased. Meanwhile, the duration of the disease was positively correlated with an increase in his or her beliefs about overuse of medication.
Discussion The characteristics of patients who participated in this study are similar to those in the national Jordanian report 2008 (Jordanian Cancer Registry, 2008). More than half of the participants in the current study were male, educated, and married. Also, the mean SBP was 142.2 mmHg (SD = 18.8) and DBP was 92 mmHg (SD = 11.2), which is similar to other studies that were carried out in Jordan (Al-Nsour et al., 2012; Jaddou et al., 2011). The BS level for participants in this study was high, with a mean of 174.4 mg/dl (SD = 79.9), which is congruent with results of other studies (Ajlouni et al., 2008; Al-Nsour et al., 2012). These results indicate that the clinical and demographic characteristics of the participants are representative of those members of the Jordanian population who are chronically ill. The BMQ was originally validated in English and this study confirmed that the Arabic version of the original BMQ is valid and reliable, and therefore appropriate to be used in an Arabic community. This work represents the first validation of this tool into the Arabic language. However, there is a variation in the reliability of BMQ subscales. This might be resulted from Muslim culture that shapes personal beliefs and attitudes which differ from Western (Chia, Schlenk, & Dunbar-Jacob, 2006). The low reliability of the
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GH and GO subscales might mean that these subscales are not sensitive enough to reflect and distinguish between positive and negative belief of Muslim patient. Therefore, more items may be needed to add or modify. This suggests that future research is needed to modify the Arabic version of BMQ and validate it. The BMQ was originally developed for use with patients suffering from chronic illnesses (asthmatic, diabetic, and psychiatric in outpatient clinic and cardiac, general medical, and renal inpatient (Horne et al., 1999)). However, in this study the outpatient clinic was the only setting and we did not include psychiatric or mental health settings. Our results support the high discriminatory value of the BMQ for identification of beliefs about medication among chronic disease patients in Jordan. The prevalence of hypertension in 2009 was 32.3% (Jaddou et al., 2011); the prevalence of diabetes in 2006 was 24.9% (Ajlouni et al., 2008). In this study, the prevalence of hypertension and diabetes was 51.6% and 38.8%, respectively. This might be because the age of the participants in this study was above 18 years which is different from Jaddou et al. (2011) and Ajlouni et al. (2008) in which the age of the participants was above 25 years. This highlights the need for a strategic health plan and policy that prevent the negative consequences, which have already been discussed by Ajlouni et al. (2012) and Al-Nsour et al. (2012) in terms of the noncommunicable diseases burden (mortality, morbidity, and increase in the cost of health services) in Jordan. In a previous study, patients admitted their need to discuss their beliefs, concerns, and problems about disease and its treatment with HCPs (Alhalaiqa et al., 2013); several studies have emphasized the importance of exploring patients’ attitudes and beliefs about disease and its treatment, to enhance patient compliance (Alhalaiqa et al., 2013; Alhalaiqa et al., 2012; Clifford, Barber, & Horne, 2008; Jin, Sklar, Oh, & Li, 2008; Nunes et al., 2009; WHO, 2003). In addition, Al-Qasem et al. (2011) reviewed 19 articles, relative to this current issue, that have been conducted in Middle Eastern countries. They found that many reasons were given by patients for nonadherence to their prescribed medication regimens; the most reported reason was related to patients’ concerns, beliefs, and attitudes. Participants in this study hold some negative beliefs (e.g., the medication is intrinsically harmful, highly/over used by HCPs), and such patients were very sensitive to its adverse events. These beliefs are similar to the results in another study by Alhalaiqa et al. (2012). Thus, these findings should be considered as a foundation for guiding care providers in their practice, particularly medication taking, use and handling by patients. Previous researchers claimed that there are patient-related factors that might affect those patients’ medication-taking behaviors (e.g., age,
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comorbidity; Jin et al., 2008; Nunes et al., 2009; Oladimeji, 2009; WHO, 2003). However, they found that there is a nondirectional relationship between age and adherence; this might be the result of differences in the patients’ beliefs regardless of their age (Jin et al., 2008). Oladimeji (2009) suggested that changes in the number of medicines were related to changes in a patient’s beliefs and their increased concerns. In this study, patient comorbidity and disease duration were positively correlated with increasing patients’ negative beliefs (overuse by HCPs and the patients’ sensitivity to medication). It is clear that the comorbidity makes doctors prescribe more than one type of medication for each type of disease. This leads to an increase in the number of medicines taken by patients; consequently, they might have some negative beliefs toward their medication in particular and medicine in general. The findings of this study are important, particularly as this is the first study conducted in this field. However, there are also limitations. Participants in this study were varied in their demographic characteristics and disease, which limit the generalizability of the findings. It should be recognized that the people in Middle East countries have hundreds of different dialects. Most dialects are usually understood among all Arabs, with the exception speakers of the Franco-Arabic dialect of Tunisia, Algeria, and Morocco; therefore, this BMQ version might be not valid for those speakers. Moreover, the backward translation process was conducted by bilingual translators whose mother language is Arabic; it was not possible to find bilingual translators whose mother tongue is English. In addition, as none of the patients spoke English, testing of both the English and Arabic versions of instruments with bilingual participants was not possible. Finally, the type of sampling procedure might reduce the generalizability of the findings.
Conclusion The Arabic version of the BMQ has satisfactory psychometric properties in terms of its validity and reliability for measuring patient beliefs about medication. Understanding the importance of exploring patients’ beliefs about medication, by using this questionnaire, should prompt the HCPs to provide high quality of care through motivating patients to resolve the discrepancies in their beliefs. This will, as it is envisaged, enhance their compliance to their prescribed medications. Also, using an Arabic version of the BMQ helps recognizing areas for potential improvement that are not related to a patient’s physical condition.
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Study Application The beliefs and perceptions of individuals toward medicine and medication are related to health behaviors (e.g., adherence). As these factors are so important for adherence, a measurement scale (e.g., BMQ) would be useful both clinically and for future research. It is critical for HCPs in Jordan to discuss and explore patients’ beliefs during health care consultation or visiting. This will improve the HCP’s relationship with the patient and help solve the discrepancy between the patient’s beliefs and behavior. BMQ could be added to the patient’s health record so the nurses are the responsible ones to administer, follow-up, and document its findings. By adding the BMQ to health record, any change in patient beliefs can be tracked and discussed to help patients choose the right decision to take their medications. A valid and reliable BMQ Arabic version opens up the door not only for Jordanian HCPs but also for those who work in Middle East countries, to use the BMQ effectively to influence patient’s expectations and symptom interpretations, as well as future attributions. In addition, understanding patients’ beliefs about medication will be helpful in designing appropriate interventions to support patients’ adherence and coping behavior with disease and its treatment. Thus, health care policy makers should enhance HCPs to explore patients’ attitudes, beliefs, and concerns toward both pharmacological and nonpharmacological treatments, to reduce the chronic disease burden in terms of comorbidity, mortality, and health care cost. This study suggests that a data gathering research instrument developed in the West can be used in a different culture, when using appropriate translation and validation process. This insight opens up the door for future research to be conducted in this field. Further studies are also needed to determine the importance of exploring patients’ beliefs in enhancing patient adherence to nonpharmacological interventions (e.g., exercise and diet). It is possible that such measurements, for example, through use of the Arabic BMQ, could be incorporated into the BRFSS, thereby enhancing this survey’s ability to identify and track the impact of attitudes and beliefs on health outcomes among Jordanian people.
Appendix Benefits About Medicines Questionnaire (BMQ-General-12) and Sensitive Soma •• These are statements that other people have made about medicines in general. •• Please show how much you agree or disagree with them by ticking the appropriate box.
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There are no right and wrong answers. We are interested in your personal views. Views about medicines in general BG1 BG2
BG9 BG3 BG4 BG11 BG10 BG6 BG5 BG12 BG7 BG8
SS1 SS2 SS3 SS4 SS5
Strongly agree
Agree
Uncertain
Disagree
Doctors use too many medicines People who take medicines should stop their treatment for a while every now and again Medicines help many people to live better lives Most medicines are addictive Natural remedies are safer than medicines In most cases, the benefits of medicines outweigh the risks In the future, medicines will be developed to cure most diseases Most medicines are poisons Medicines do more harm than good Medicines help many people to live longer Doctors place too much trust on medicines If doctors had more time with patients, they would prescribe fewer medicines My body is very sensitive to medicines My body over reacts to medicines I usually have stronger reactions to medicines than most people I have had a bad reaction to medicines in the past Even very small amounts of medicine can upset my body
Strongly disagree
Source: Horne, Weinman, and Hankins (1999).
Acknowledgments Thanks for those people, who did the translation process of Beliefs About Medication Questionnaire (BMQ), from Arabic to English and vice versa. Thanks to Dr. Nadin Abed-Alrazeq who helped us in the analysis of results. The authors are grateful to Philadelphia University, Jordan, who funded this study.
Authors’ Note The funders were not involved in the design or analysis of this study. The materials related to this study (e.g., data, samples, or models) can be accessed only by the researchers through using password to enter the computer where these data have been stored.
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Declaration of Conflicting Interests The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: One of the authors used the Beliefs About Medication Questionnaire (BMQ) in her PhD thesis.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by grant from Philadelphia University, Jordan.
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Brown, D. W., Mokdad, A., Walke, H., As’sd, M., Al-Nsour, M., & Zindah, M. (2009). Projected burden of chronic, noncommunicable diseases in Jordan (Letter). Preventing Chronic Disease, 6(2), A78. Centers for Disease Control and Prevention. (2006). Assessing risk factors for chronic disease—Jordan, 2004 (Morbidity and Mortality Weekly Report, Vol. 55, pp. 653-655). Washington, DC: Author. Chia, L., Schlenk, E., & Dunbar-Jacob, J. (2006). Effect of personal and cultural beliefs on medication adherence in the elderly. Drugs Aging, 23, 191-202. Clifford, S., Barber, N., & Horne, R. (2008). Understanding different beliefs held by adherers, unintentional nonadherers, and intentional nonadherers: Application of the necessity-concerns framework. Journal of Psychosomatic Research, 64, 41-46. Foley, K. A., Vasey, J., Berra, K., Alexander, C. M., & Markson, L. E. (2005). The Hyperlipidemia: Attitudes and Beliefs in Treatment (HABIT) Survey for Patients: Results of a Validation Study. Journal of Cardiovascular Nursing, 20, 35-42. George, D., & Mallery, P. (2003). PSS for Windows step by step: A simple guide and reference. 11.0 update (4th ed.). Boston, MA: Allyn & Bacon. Haynes, R., Ackloo, E., Sahota, N., & McDonald, H. P. (2008). Interventions for enhancing medication adherence. Cochrane Database of Systematic Review, 16(2), CD000011. 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, 4, 1-24. Jaddou, H. Y., Batieha, A. M., Khader, Y. S., Kanaan, A. H., El-Khateeb, M. S., & Ajlouni, K. M. (2011). Hypertension prevalence, awareness, treatment and control, and associated factors: Results from a National Survey, Jordan. International Journal of Hypertension, 2011, Article 828797. Janz, N. K., & Becker, M. H. (1984). The Health Belief Model: A decade later. Health Education & Behavior, 11, 1-47. Jin, J., Sklar, G., Oh, V., & Li, S. (2008). Factors affecting therapeutic compliance: A review from the patient’s perspective. Therapeutics and Clinical Risk Management, 4, 269-286. Jordanian Cancer Registry. (2008). National cancer statistics, cancer incidence in Jordan.Retrieved from http://www.moh.gov.jo/AR/Documents/Jordan%20 Cancer%20Registry_2008%20Report.pdf Klein, M., Heimans, J. J., Aaronson, N. K., van der Ploeg, H. M., Grit, J., Muller, M., . . . Taphoorn, M. J. (2002). Effect of radiotherapy and other treatment-related factors on mid-term to long-term cognitive sequelae in low-grade gliomas: A comparative study. The Lancet, 360, 1361-1368. Leeder, S., Raymond, S., Greenberg, H., Liu, H., & Esson, K. (2004). A race against time: The challenge of cardiovascular disease in developing economies. New York, NY: Columbia University. Malkawi, K. (2012, June 26). Chronic diseases pushing Jordan toward crisis— Ajlouni. The Jordan Times. Retrieved from http://jordantimes.com/chronicdiseases-pushing-jordan-toward-crisis—ajlouni
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Ministry of Health. (2008). Mortality in Jordan 2005. Amman: Directorate of Information Studies and Research, Ministry of Health, The Hashemite Kingdom of Jordan. Morrison, A., Wertheimer, A. I., & Berger, M. L. (2000). Interventions to improve antihypertensive drug adherence: A quantitative review of trials. Formulary, 35, 234-255. Nunes, V., Neilson, J., O’Flynn, N., Calvert, N., Kuntze, S., Smithson, H., . . . Steel, J. (2009). Clinical guidelines and evidence review for medicines adherence: Involving patients in decisions about prescribed medicines and supporting adherence. London, England: National Collaborating Centre for Primary Care and Royal College of General Practitioners. Oladimeji, O. O. (2009). Concern beliefs in medicines: Description, changes over time and impact on patient outcomes (Doctoral dissertation, University of Iowa). Retrieved from http://ir.uiowa.edu/etd/314 Perpiñá Tordera, M., Martínez Moragón, E., Belloch Fuster, A., Lloris Bayo, A., & Pellicer Císcar, C. (2009). Spanish asthma patients’ beliefs about health and medicines: Validation of 2 questionnaires. Archivos de Bronconeumología, 45, 218-223. doi:10.1016/S1579-2129(09)72151-2 Riekert, K., & Drotar, D. (2002). The Beliefs About Medication Scale: Development, reliability, and validity. Journal of Clinical Psychology in Medical Settings, 9, 177-184. Rosenstock, I. M. (1974). Historical origins of the health belief model. Health Education & Behavior, 2, 328-335. Salgado, T., Marques, A., Geraldes, L., Benrimoj, S., Horne, R., & Fernandez-Llimos, F. (2013). Cross-cultural adaptation of the Beliefs about Medicines Questionnaire into Portuguese. Sao Paulo Medical Journal, 131, 88-94. World Health Organization. (2003). Adherence to long-term therapies evidence for action. Geneva, Switzerland: Author. World Health Organization. (2009). 2008-2013 Action plan for the global strategy for the prevention and control of noncommunicable diseases. Geneva, Switzerland: Author. World Health Organization. (2013). Process of translation and adaptation. Retrieved fromhttp://www.who.int/substance_abuse/research_tools/translation/en/
Author Biographies Fadwa Alhalaiqa, PhD, CNS, RN, is an assistant professor at Philadelphia University Faculty of Nursing, Amman 19392, Jordan. She is the corresponding author. Rami Masa’Deh, PhD, is an assistan professor at Applied Science Private University, Faculty of Nursing. Abdul-Monim Batiha, PhD is an associate professor at Philadelphia University faculty of Nursing. Katherine Deane, BSc, PhD is a senior lecturer in research at University of East Anglia school of Nursing Sciences.
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CNRXXX10.1177/1054773814545383Clinical Nursing ResearchAlhalaiqa et al.
Article
Validity of Arabic Version of Beliefs About Medication Questionnaire
Clinical Nursing Research 1–17 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1054773814545383 cnr.sagepub.com
Fadwa Alhalaiqa, PhD, CNS, RN1, Rami Masa’Deh, PhD2, Abdul-Monim Batiha, PhD1, and Katherine Deane, BSc, PhD3
Abstract To assess the validity and reliability of the Arabic version of the Beliefs About Medication Questionnaire, a cross-sectional design was used and the data were collected from 605 patients with chronic diseases. The study was conducted between July 2013 and December 2013. The results showed that the Cronbach’s alpha coefficient (.71) was satisfactory. There was a significant strong positive correlation between test–retest for the same group subsample, with a correlation coefficient range of .45 to .78. There were no statistically significant differences between retest subgroups and remaining samples in the questionnaire subscales. The percentage of missing value was around 0.03, which confirmed the feasibility of the Arabic version of the questionnaire. These findings suggested that having a culturally acceptable, valid and reliable instrument to identify patients’ beliefs toward medication in Jordan will play an important role in tailoring appropriate intervention to enhance patient compliance with their prescribed medication.
1Faculty
of Nursing, Philadelphia University, Amman, Jordan of Nursing, Applied Science Private University, Amman, Jordan 3School of Nursing Sceinces, University of East Anglia, Norwich, UK 2Faculty
Corresponding Author: Fadwa Alhalaiqa, PhD, CNS, RN, Faculty of Nursing, Philadelphia University, Amman 19392, Jordan. Email: [email protected], [email protected]
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Keywords beliefs, medication, reliability, validity, compliance
Introduction Beliefs are playing an important role in patient health behaviors (Janz & Becker, 1984). This is supported by the development of a health belief model in 1950 (Rosenstock, 1974). The guidelines developed by the World Health Organization (WHO, 2003) and National Institute for Clinical Excellence (NICE) recommended health care professionals to explore patient’s concerns, attitudes, and beliefs toward medication as these were the most critical causes of nonadherence among chronic disease patients (Horne, Weinman, & Hankins, 1999; Morrison, Wertheimer, & Berger, 2000; Nunes et al., 2009). This exploration was the main aim of Western researchers, therefore they developed many instruments, one being the Beliefs About Medication Questionnaire (BMQ), developed by Horne et al. (1999). This current study aims to validate the Arabic version of the BMQ.
Background The prevention and management of chronic disease in Jordan is becoming an important issue for health care providers (HCPs). There is a high prevalence of chronic diseases in Jordan (e.g., hypertension and diabetes) together with their risk factors (e.g., obesity, overweight, cigarette smoking, high cholesterol level; Al-Nsour et al., 2012; Malkawi, 2012). By 2050, 3.5 million (50%) people in Jordan are expected to have diabetes mellitus, 3.7 million (53%) with hypertension, and 2.93 million (41%) with high cholesterol (Brown, et al., 2009). Thus, the burden of noncommunicable diseases in Jordan is increasing (Malkawi, 2012; Al-Nsour et al., 2012). In 2004, the direct and indirect costs of treating chronic diseases (e.g., diabetes, hypertension, obesity, and high cholesterol) in Jordan was 1.3 billion Jordanian dinars (equal to US$1.82 billion; Malkawi, 2012). In 2005, chronic diseases were considered to be responsible for more than 50% of deaths in Jordan (Ministry of Health [MOH], 2008). By 2030, two thirds of deaths in the Middle East region will be as a result of noncommunicable diseases (Brown et al., 2009). By 2020, the mortality rate in developing countries from ischemic heart diseases is expected to increase by 120% for women and 137% for men (Leeder, Raymond, Greenberg, Liu, & Esson, 2004). Although the treatment of chronic diseases by medication is well established, most of the patients do not adhere to taking their medication as their doctor has prescribed (Haynes, Ackloo,
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Sahota, & McDonald, 2008; WHO, 2003, 2009). WHO (2003) reported that medication adherence rates are around 50% for patients suffering from chronic diseases in developed countries. Nonadherence rates in developing countries are considered to be much higher, with Al-Qasem et al. (2011) estimating the nonadherence rate to be as high as 88% in the Middle East. Patients who doubt that their medicines will positively affect their health, and who are concerned about their body’s response to medication and its potentially negative side effects, are less likely to be compliant in taking their medicines than those who have positive beliefs and attitudes (Ajlouni, Khader, Batieha, Ajlouni, & El-Khateeb, 2008; Alhalaiqa, Deane, & Gray, 2013; Alhalaiqa, Deane, Nawafleh, Clark, & Gray, 2012; Horne et al., 1999). An adherence therapy intervention that explored patients’ attitudes and beliefs has improved hypertensive patients’ compliance to the taking of their medication but also had a positive effect on clinical markers of risk, that is, blood pressure (BP), thus reducing the patient’s risk of complications and mortality (Alhalaiqa et al., 2013; Alhalaiqa et al., 2012; Horne et al., 1999). So, by addressing patient’s attitudes and beliefs and improving regimen adherence, it is arguable that the burden of chronic diseases would be reduced (Alhalaiqa et al., 2012; Malkawi, 2012; WHO, 2003). One key goal of the national health system in Jordan is to prevent and control these long-term conditions by providing effective health services. The Jordan MOH, in cooperation with the Jordan Department of Statistics, the WHO, and the Centers for Disease Control and Prevention (CDC), established the Jordan Behavioral Risk Factor Surveillance Survey (BRFSS) to decrease the burden of chronic diseases. BRFSS is used to collect data on health risk behaviors, clinical preventive health practices, and health care access that are associated with leading causes of illness and death in Jordan (CDC, 2006). Unfortunately, the BRFSS does not measure a patient’s attitudes and beliefs toward medication, factors that are considered to be the corner stone in determining the patient’s level of adherence to their medication regimen, which is a crucial health behavior indicator that could prevent disease complications. There are many instruments available to explore patients’ beliefs toward medication (e.g., Hyperlipidemia: Attitudes and Beliefs in Treatment [HABIT]; Foley, Vasey, Berra, Alexander, & Markson, 2005), the Beliefs About Medication Compliance Scale (Bennett, Milgrom, Champion, & Huster, 1997; Riekert & Drotar, 2002). However, the most commonly used is the BMQ (Alhalaiqa et al., 2012; Perpiñá Tordera, Martínez Moragón, Belloch Fuster, Lloris Bayo, & Pellicer Císcar, 2009; Salgado et al., 2013). The specific BMQ is used to measure particular groups of patients and their beliefs regarding specific types of drugs. The general BMQ is used to analyze patients’ beliefs involving broader concepts (Horne et al., 1999).
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At present, there are no instruments that measure patients’ beliefs and attitudes toward their medications, which have been designed or adapted for Arabic culture and language. In addition, many Arabic researchers have asked to use the Arabic version of the BMQ, which had been used by Alhalaiqa et al. (2012). Therefore, the aim of this study was to validate the Arabic version of BMQ.
Method Study Design A cross-sectional survey design was used. The questionnaire survey was completed by people who are affected by one or more chronic diseases. After obtaining permission to use the BMQ from the developer of the original English version (Horne et al., 1999), translation of the BMQ into Arabic was done, based on an internationally accepted translation process (Brislin, 1970, 1986; Brislin, Lonner, & Throndike, 1973; WHO, 2013). An expert panel was selected to monitor the adaptation procedure of the BMQ. The main two steps of translation were forward and backward by two professional bilingual persons with medical backgrounds. One translator was a cardiologist and the other a nursing lecturer at Al-Hashmiah University. They independently translated the original English measures into Arabic, and then combined the translations from these two copies to create a single Arabic version. Another two bilingual translators did the backward translation. One translator was an English master’s student and the other one was a registered nurse with a master’s degree. A final English version of each measure was then sent to the original authors. There were no changes made to the back-translated version. All the authors were satisfied with the final English versions. To test clarity, comprehensiveness, appropriateness, and cultural relevance, the final version (the appendix) of the questionnaire was tested on 20 candidates (other than those who were included in the validation sample) before conducting the actual study. All participants were interviewed and encouraged to give comments on the measures. Minor revisions were made to the Arabic version of the instrument, based on the results of interviews, without any change to the conceptual meanings.
Participants and Setting The convenience sample procedure was used. The sample size was calculated by using a power equation to be 400 patients, based on the confidence interval of 1.96, margin of error of 5% and 45% the prevalence of chronic diseases in Jordan. The drop-out rate was calculated and considered to have a sample
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size of 500 patients. The inclusion criteria were a chronic disease patient aged 18 years or above, who was taking regular medications, able to read and write Arabic, had no obvious cognitive deficit, and had follow-up appointments at an outpatient clinic. The aim of the research was to cover most areas in Jordan. As there are three main geographical regions in the country (north, middle, and south), we selected the hospitals which provide health care service for most Jordanians. Therefore, the study was carried out in three multidisciplinary centers (Jordan MOH and private hospitals).
Ethical Considerations The study was approved by all hospitals from which the participants were recruited. Informed consent was gained from all participants before starting the study. Patient privacy and confidentiality were maintained. We explained to participants that they have the right to freely participate in the study and can withdraw at any time without giving any reasons and their withdrawal would not affect the health services provided to them.
Data Collection Methods Self-reported questionnaires were used to collect the data. The general version BMQ12 which is designed to measure positives (e.g., benefits) and negative beliefs and attitudes (e.g., over use) was employed (Horne et al., 1999). It has four sections with a total of 17 items. Each question is rated on a 5-point Likert-type scale, with a score of 5 indicating strongly agree, to measure the following: 1. Harm (GH): the harmful characteristics of medication (four questions). 2. Overuse (GO): (overprescribing) the way of prescribing medications by (HCPs; four questions). 3. General sensitivity (GS): sensitivity of the patients to adverse events from medications (five questions). 4. General benefit (GB): the positive properties of medication (four questions). Sociodemographic factors including age, gender, educational, marital, employment status, comorbidity (presence of other diseases), duration of the disease, BP, and blood sugar (BS) were measured through a questionnaire that was developed for the purpose of this specific study.
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Recruitment Procedure Research assistants (RAs) were trained to handle the questionnaire in the same manner (to reduce the risk of assessment bias). Participants were recruited by reviewing patients’ health records in clinics by RAs. An information sheet was given to all participants who met the inclusion criteria. After signifying their agreement, all participants were interviewed by the RAs and completed the Arabic BMQ version and demographic questionnaire (the average time needed by each participant to fill in the questionnaires was 15 min). After 2 weeks, the BMQ was administered for the second time in a subsample (n = 132) of patients by the RAs.
Data Analysis Descriptive statistics were used to describe the sample; the quantitative variables were described by using mean and standard deviation (SD); qualitative variables were described using frequency and percentages. The questionnaire’s internal consistency was assessed by measuring Cronbach’s alpha coefficient. Values equal to or greater than .70 were considered satisfactory (Bland & Altman, 1996). The test–retest reliability was done by using Pearson’s product–moment correlation coefficient. The Mann–Whitney U test was used to determine whether there are differences between the retest subgroup and the remaining study sample. The feasibility of the Arabic version of the BMQ was determined; based on the percentage of missing responses for each item. Floor and ceiling effects of each score of the BMQ were calculated as the percentage of subjects achieving the lowest and highest possible score. Additional analysis, including bivariate correlations, was used to examine the associations of BMQ subscale scores with the variables of interest (age, comorbidity, and duration of disease) as well as to identify if there are any relationships between BMQ subscale and these demographic variables.
Results Participants’ Characteristics The study was conducted between July 2013 and December 2013. Data were collected from 605 patients. Their demographic data showed that their mean age was around 55.9 years (SD = 12.5). The majority of participants were Jordanian (n = 559), more than 50% of them were male (53%, n = 321) and 51% were not working at the time of conducting the study (n = 314). More than three quarters of the participants were educated (at least they finished
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Alhalaiqa et al. Table 1. Demographical Characteristics.
Age Level of income Gender Male Female Nationality Jordanian Other Education Educateda Noneducated Marital status Married Single Widowed Insurance Insured Noninsured Occupation Working Not working Retired aEducated
Minimum
Maximum
M
19.00 0.00
86.00 1,500.00
55.9 (12.6) 396.7 (182.1)
Frequency
%
321 284
53.1 46.9
559 46
92.4 7.6
514 91
85 15
526 26 53
86.9 4.3 8.8
480 125
79.3 20.7
139 314 152
23 51.9 25.1
means has at least finished the secondary school.
the secondary school; 85%, n = 514), married (87%, n = 526), had health insurance (79%, n = 480; see Table 1). Table 2 shows the clinical characteristics of the participants; around 42% of them having comorbidity (two or more types of disease). The most common diagnoses were hypertension and diabetes (52% and 39%, respectively) with disease duration of more than 5 years (around 56%). The participants’ mean systolic blood pressure (SBP) was 142 mmHg (SD = 18.8), diastolic (DBP) was 92 mmHg (SD = 11.2), and their BS was 174 mg/dl (SD = 79.9). Regarding the BMQ subscales, participants in this study believed that the medication is over prescribed and over used by HCPs (M = 15.1; SD = 2.9); intrinsically harmful (M = 14.2; SD = 3.4); and they were very sensitive to its
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Table 2. Clinical Characteristics. Frequency
%
349 216 40
57.7 35.7 6.6
312 235 14 14 20 10
51.6 38.8 2.3 2.3 3.3 1.7
264 179 159
43.6 29.6 26.3
Comorbidity one disease Two types of diseases More than two types of diseases Medical diagnosis Hypertension Diabetes Chronic renal failure Respiratory Cardiovascular Others Disease duration (years) 1-5 More than 5 to 10 More than 10 SBP, mmHg DBP, mmHg Blood sugar level, mg/dl GH GO GB GS
Minimum
Maximum
M (SD)
90.00 50.00 69.00 7 8 8 7
195.00 150.00 500.00 52 45 20 54
142.2 (18.8) 92.1 (11.2) 174.4 (79.9) 14.2 (3.4) 15.1 (2.9) 15.3 (2.6) 17.1 (2.5)
Note. SBP = systolic blood pressure; DBP = diastolic blood pressure; GH = harm; GO = overuse; GB = general benefit; GS = general sensitivity.
adverse events (M = 17.1; SD = 2.5). However, they believed that there were some positive properties for the medication (M = 15.3; SD = 2.6).
Reliability of BMQ According to George and Mallery (2003) and Kline et al. (2002), the questionnaire has good internal consistency, with a Cronbach’s alpha coefficient reported between .7 ≤ α < .9. In the current study, the Cronbach’s alpha coefficient for the total questionnaire was .71. However, the BMQ subscales had acceptable reliability for GS and GB (Cronbach’s α scores were .65 and .55, respectively), while the negative beliefs and statements about GH and GO subscales had poor reliability (Cronbach’s α scores were .35 and .3, respectively).
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Table 3. Pearson’s Product–Moment Correlation Between BMQ Items at Baseline and After 2 Weeks. BMQ items
Pearson’s correlation (r)
p value
.456** .724** .778** .788**
.000 .000 .000 .000
GH GO GB GS
Note. BMQ = Beliefs About Medication Questionnaire; GH = harm; GO = overuse; GB = general benefit; GS = general sensitivity. **Correlation is significant at the .01 level (two-tailed).
Table 4. Mann–Whitney U Test Statistics.
Mann–Whitney U z p value
GO
GH
GB
GS
37,956.000 −1.180 .238
25,785.000 −6.658 .000
28,045.000 −5.794 .000
37,850.500 −1.279 .201
Note. Grouping variable: group. GO = overuse; GH = harm; GB = general benefit; GS = general sensitivity.
Test–Retest Reliability As shown in Table 3, scores were reliable over an interval of 2 weeks. Pearson’s product–moment correlation coefficient was employed for the same subgroups after 2 weeks and it ranged from .45 to .78 for the entire sample. There was a significant, strong positive correlation between the BMQ items at Time 1 and Time 2.
Differences in BMQ Subscales There were no statistically significant differences between the two groups (retest subgroup and remaining sample) in the BMQ subscales; GO and GS (see Table 4). However, the differences between groups in terms of GB and GH of the BMQ subscales were significant (p = .000).
The Feasibility of BMQ The Arabic version of the BMQ is feasible because the percentage of missing value for each item was only around 0.03.
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The Ceiling and Floor Effects The distribution of participants’ responses, evaluated by ceiling and floor effects, showed appropriate proportions and good discrimination of BMQ items.
Additional Analysis The relationship between age and BMQ subscales was investigated by using the bivariate correlation. The results showed that there was a small positive correlation between age and perceived general medication overuse and benefit (r = .23, n = 604, p = .000; r = .1, n = 604, p = .010), respectively. An increase of the age of the patient was correlated with an increase in his or her beliefs about overuse of medication as prescribed by their doctor and the benefit of the medication to the patient. The relationship between comorbidity and BMQ subscales was tested. The results indicate that for a patient who had more than one type of disease, his or her beliefs about the overuse of the medication prescribed by doctors, and that patient’s sensitivity to medication, were increased. Meanwhile, the duration of the disease was positively correlated with an increase in his or her beliefs about overuse of medication.
Discussion The characteristics of patients who participated in this study are similar to those in the national Jordanian report 2008 (Jordanian Cancer Registry, 2008). More than half of the participants in the current study were male, educated, and married. Also, the mean SBP was 142.2 mmHg (SD = 18.8) and DBP was 92 mmHg (SD = 11.2), which is similar to other studies that were carried out in Jordan (Al-Nsour et al., 2012; Jaddou et al., 2011). The BS level for participants in this study was high, with a mean of 174.4 mg/dl (SD = 79.9), which is congruent with results of other studies (Ajlouni et al., 2008; Al-Nsour et al., 2012). These results indicate that the clinical and demographic characteristics of the participants are representative of those members of the Jordanian population who are chronically ill. The BMQ was originally validated in English and this study confirmed that the Arabic version of the original BMQ is valid and reliable, and therefore appropriate to be used in an Arabic community. This work represents the first validation of this tool into the Arabic language. However, there is a variation in the reliability of BMQ subscales. This might be resulted from Muslim culture that shapes personal beliefs and attitudes which differ from Western (Chia, Schlenk, & Dunbar-Jacob, 2006). The low reliability of the
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GH and GO subscales might mean that these subscales are not sensitive enough to reflect and distinguish between positive and negative belief of Muslim patient. Therefore, more items may be needed to add or modify. This suggests that future research is needed to modify the Arabic version of BMQ and validate it. The BMQ was originally developed for use with patients suffering from chronic illnesses (asthmatic, diabetic, and psychiatric in outpatient clinic and cardiac, general medical, and renal inpatient (Horne et al., 1999)). However, in this study the outpatient clinic was the only setting and we did not include psychiatric or mental health settings. Our results support the high discriminatory value of the BMQ for identification of beliefs about medication among chronic disease patients in Jordan. The prevalence of hypertension in 2009 was 32.3% (Jaddou et al., 2011); the prevalence of diabetes in 2006 was 24.9% (Ajlouni et al., 2008). In this study, the prevalence of hypertension and diabetes was 51.6% and 38.8%, respectively. This might be because the age of the participants in this study was above 18 years which is different from Jaddou et al. (2011) and Ajlouni et al. (2008) in which the age of the participants was above 25 years. This highlights the need for a strategic health plan and policy that prevent the negative consequences, which have already been discussed by Ajlouni et al. (2012) and Al-Nsour et al. (2012) in terms of the noncommunicable diseases burden (mortality, morbidity, and increase in the cost of health services) in Jordan. In a previous study, patients admitted their need to discuss their beliefs, concerns, and problems about disease and its treatment with HCPs (Alhalaiqa et al., 2013); several studies have emphasized the importance of exploring patients’ attitudes and beliefs about disease and its treatment, to enhance patient compliance (Alhalaiqa et al., 2013; Alhalaiqa et al., 2012; Clifford, Barber, & Horne, 2008; Jin, Sklar, Oh, & Li, 2008; Nunes et al., 2009; WHO, 2003). In addition, Al-Qasem et al. (2011) reviewed 19 articles, relative to this current issue, that have been conducted in Middle Eastern countries. They found that many reasons were given by patients for nonadherence to their prescribed medication regimens; the most reported reason was related to patients’ concerns, beliefs, and attitudes. Participants in this study hold some negative beliefs (e.g., the medication is intrinsically harmful, highly/over used by HCPs), and such patients were very sensitive to its adverse events. These beliefs are similar to the results in another study by Alhalaiqa et al. (2012). Thus, these findings should be considered as a foundation for guiding care providers in their practice, particularly medication taking, use and handling by patients. Previous researchers claimed that there are patient-related factors that might affect those patients’ medication-taking behaviors (e.g., age,
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comorbidity; Jin et al., 2008; Nunes et al., 2009; Oladimeji, 2009; WHO, 2003). However, they found that there is a nondirectional relationship between age and adherence; this might be the result of differences in the patients’ beliefs regardless of their age (Jin et al., 2008). Oladimeji (2009) suggested that changes in the number of medicines were related to changes in a patient’s beliefs and their increased concerns. In this study, patient comorbidity and disease duration were positively correlated with increasing patients’ negative beliefs (overuse by HCPs and the patients’ sensitivity to medication). It is clear that the comorbidity makes doctors prescribe more than one type of medication for each type of disease. This leads to an increase in the number of medicines taken by patients; consequently, they might have some negative beliefs toward their medication in particular and medicine in general. The findings of this study are important, particularly as this is the first study conducted in this field. However, there are also limitations. Participants in this study were varied in their demographic characteristics and disease, which limit the generalizability of the findings. It should be recognized that the people in Middle East countries have hundreds of different dialects. Most dialects are usually understood among all Arabs, with the exception speakers of the Franco-Arabic dialect of Tunisia, Algeria, and Morocco; therefore, this BMQ version might be not valid for those speakers. Moreover, the backward translation process was conducted by bilingual translators whose mother language is Arabic; it was not possible to find bilingual translators whose mother tongue is English. In addition, as none of the patients spoke English, testing of both the English and Arabic versions of instruments with bilingual participants was not possible. Finally, the type of sampling procedure might reduce the generalizability of the findings.
Conclusion The Arabic version of the BMQ has satisfactory psychometric properties in terms of its validity and reliability for measuring patient beliefs about medication. Understanding the importance of exploring patients’ beliefs about medication, by using this questionnaire, should prompt the HCPs to provide high quality of care through motivating patients to resolve the discrepancies in their beliefs. This will, as it is envisaged, enhance their compliance to their prescribed medications. Also, using an Arabic version of the BMQ helps recognizing areas for potential improvement that are not related to a patient’s physical condition.
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Study Application The beliefs and perceptions of individuals toward medicine and medication are related to health behaviors (e.g., adherence). As these factors are so important for adherence, a measurement scale (e.g., BMQ) would be useful both clinically and for future research. It is critical for HCPs in Jordan to discuss and explore patients’ beliefs during health care consultation or visiting. This will improve the HCP’s relationship with the patient and help solve the discrepancy between the patient’s beliefs and behavior. BMQ could be added to the patient’s health record so the nurses are the responsible ones to administer, follow-up, and document its findings. By adding the BMQ to health record, any change in patient beliefs can be tracked and discussed to help patients choose the right decision to take their medications. A valid and reliable BMQ Arabic version opens up the door not only for Jordanian HCPs but also for those who work in Middle East countries, to use the BMQ effectively to influence patient’s expectations and symptom interpretations, as well as future attributions. In addition, understanding patients’ beliefs about medication will be helpful in designing appropriate interventions to support patients’ adherence and coping behavior with disease and its treatment. Thus, health care policy makers should enhance HCPs to explore patients’ attitudes, beliefs, and concerns toward both pharmacological and nonpharmacological treatments, to reduce the chronic disease burden in terms of comorbidity, mortality, and health care cost. This study suggests that a data gathering research instrument developed in the West can be used in a different culture, when using appropriate translation and validation process. This insight opens up the door for future research to be conducted in this field. Further studies are also needed to determine the importance of exploring patients’ beliefs in enhancing patient adherence to nonpharmacological interventions (e.g., exercise and diet). It is possible that such measurements, for example, through use of the Arabic BMQ, could be incorporated into the BRFSS, thereby enhancing this survey’s ability to identify and track the impact of attitudes and beliefs on health outcomes among Jordanian people.
Appendix Benefits About Medicines Questionnaire (BMQ-General-12) and Sensitive Soma •• These are statements that other people have made about medicines in general. •• Please show how much you agree or disagree with them by ticking the appropriate box.
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There are no right and wrong answers. We are interested in your personal views. Views about medicines in general BG1 BG2
BG9 BG3 BG4 BG11 BG10 BG6 BG5 BG12 BG7 BG8
SS1 SS2 SS3 SS4 SS5
Strongly agree
Agree
Uncertain
Disagree
Doctors use too many medicines People who take medicines should stop their treatment for a while every now and again Medicines help many people to live better lives Most medicines are addictive Natural remedies are safer than medicines In most cases, the benefits of medicines outweigh the risks In the future, medicines will be developed to cure most diseases Most medicines are poisons Medicines do more harm than good Medicines help many people to live longer Doctors place too much trust on medicines If doctors had more time with patients, they would prescribe fewer medicines My body is very sensitive to medicines My body over reacts to medicines I usually have stronger reactions to medicines than most people I have had a bad reaction to medicines in the past Even very small amounts of medicine can upset my body
Strongly disagree
Source: Horne, Weinman, and Hankins (1999).
Acknowledgments Thanks for those people, who did the translation process of Beliefs About Medication Questionnaire (BMQ), from Arabic to English and vice versa. Thanks to Dr. Nadin Abed-Alrazeq who helped us in the analysis of results. The authors are grateful to Philadelphia University, Jordan, who funded this study.
Authors’ Note The funders were not involved in the design or analysis of this study. The materials related to this study (e.g., data, samples, or models) can be accessed only by the researchers through using password to enter the computer where these data have been stored.
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Declaration of Conflicting Interests The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: One of the authors used the Beliefs About Medication Questionnaire (BMQ) in her PhD thesis.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by grant from Philadelphia University, Jordan.
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Author Biographies Fadwa Alhalaiqa, PhD, CNS, RN, is an assistant professor at Philadelphia University Faculty of Nursing, Amman 19392, Jordan. She is the corresponding author. Rami Masa’Deh, PhD, is an assistan professor at Applied Science Private University, Faculty of Nursing. Abdul-Monim Batiha, PhD is an associate professor at Philadelphia University faculty of Nursing. Katherine Deane, BSc, PhD is a senior lecturer in research at University of East Anglia school of Nursing Sciences.
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