The 16-item ASMQ is valid and reliable and corresponds to change in clinical asthma status over time. The questionnaire addresses knowledge of preventive strategies, proper use of inhalers, differences between rescue and maintenance medications, and use of peak flow meters. A major strength of the questionnaire is that it was not developed a priori by physicians but instead was derived during an iterative process based on feedback from patients. As such, the questions address real day-to-day situations and decisions faced by patients, and the incorrect response options reflect misconceptions that patients have about managing asthma. Thus, the final patient-derived questionnaire captures self-management issues from the patient’s point of view.
An important goal in developing the questionnaire was to balance ease of administration with comprehensiveness. To increase comprehensiveness, we used a multiple-choice response format, which permitted us to expand the breadth of the material covered per question. This is beneficial because reasons why certain responses are incorrect can be discussed when the questionnaire is reviewed with patients. In addition, offering the response option of “I don’t know” decreases the chances of guessing the correct answers and also communicates to patients that not knowing correct answers is anticipated and acceptable. When presenting the questionnaire to patients, we encouraged them to choose this option, where applicable, to identify what topics we needed to focus on during subsequent discussions.
To maximize ease of administration, we composed short phrases for questions and responses. The questionnaire has a Flesch-Kincaid reading level of grade 6.8 and requires approximately 5 minutes to complete when self-administered. When administered during an interview, approximately 8 to 10 minutes should be allocated to repeat questions and responses if necessary. We found the questionnaire to be well received by patients when administered both ways. In addition, we found that questions about rescue and maintenance medications were better understood if names of familiar medications were given as examples. Therefore, we recommend the patient’s medications be cited in these questions, or representative examples of medications be cited if the questionnaire is given to a group of patients, such as in a research trial.
Although recruited from the same practice, patients in the testing and demonstration samples differed somewhat clinically. These differences were due to variations in eligibility criteria for the parent trials from which these patients were drawn. For example, patients in the demonstration sample were enrolled in a trial to increase walking and exercise and thus tended to have milder symptoms, to not require maintenance medications, and to have better asthma-related quality-of-life scores. Including patients with different disease severity in the various phases, however, permitted us to evaluate the ASMQ in patients with a range of clinical conditions.
We tested our questionnaire against the 20-item knowledge subscale of the KASE-AQ, a reliable general questionnaire that measures various aspects of asthma knowledge.3
The KASE-AQ was developed to account for patient-centered factors that may contribute to difficulties in managing asthma. The factors measured by the KASE-AQ were found to be associated with certain outcomes, such as medication compliance and the use of emergency asthma care.12
Other scales, such as the 31-item Asthma General Knowledge Questionnaire for Adults, were developed to evaluate effectiveness of asthma educational programs and showed improvement in areas specifically addressed by the programs.4,5
The National Heart, Lung, and Blood Institute assembled a survey of 9 questions entitled “Check Your Asthma IQ,” which offers a simple way to increase patients’ awareness of issues related to asthma.20
This brief quiz showed poor understanding of asthma among patients who presented to the emergency department for exacerbations.8,11
Also, several general knowledge questionnaires have been developed specifically for pediatric asthma patients and their caregivers.6,21
With the exception of the KASE-AQ, which has multiple-choice responses, most of these other questionnaires have true or false responses with a third option to cover uncertainty.5,6,20
Although simpler to complete, these questionnaires are less likely to depict the process patients use in making treatment decisions. At the other end of the spectrum, several studies evaluated self-management knowledge by presenting patients with narratives of asthma exacerbations and asking them open-ended questions about what actions they would take at various stages.22,23
Points were assigned for actions that were appropriate at each stage. Although this technique approximates clinical reality, it is time consuming and difficult to administer to large groups of patients.
This study has several limitations. First, it was developed in an urban primary care practice and may not reflect self-management issues of patients in other settings. Second, there is no standard method to measure test-retest reliability for an informational questionnaire because the learning effect from the first administration may affect responses to the second administration. Therefore, we reported both the Pearson and intraclass correlation coefficients. Third, to establish validity it would have been ideal to compare the ASMQ with observed or documented self-management behaviors. In addition, the utility of the ASMQ in clinical practice would be confirmed by measuring changes in behavior resulting from completing the questionnaire and discussing it with physicians. Fourth, we did not formally test responsiveness during a longer period or time in the demonstration sample because we did not administer the self-management intervention according to a set protocol. However, all patients in the demonstration sample received information about self-management through a workbook and periodic reinforcements by telephone. Therefore, our finding that asthma quality-of-life and ASMQ scores changed in parallel provides preliminary evidence that the ASMQ corresponds to clinical status over time.
The ASMQ is a valid and reliable questionnaire that is associated with effective self-management behaviors and outcomes. It addresses multiple aspects of self-management and can be used in clinical and research settings.