Cultural adaptation and validation of the Attitudes About Complex Therapy Scale to European Portuguese
DOI:
https://doi.org/10.32385/rpmgf.v41i4.14002Keywords:
Diabetes mellitus, Type 2, Polypharmacy, Therapeutics, Management, AdherenceAbstract
Objectives: To perform the cultural adaptation of the Attitudes about Complex Therapy Scale (ACTS) to European spoken Portuguese as a scale of Atitudes Perante Terapêutica Complexa (APTC) and convergent validation with the Problems Areas in Diabetes-5 (PAID-5) scale.
Methods: Translation into European Portuguese, linguistic verification, and back-translation into English, followed by an internal consistency analysis, comprehensibility, and reliability. Convergent validation was performed using the PAID-5 scale and context variables, including sex, age group, and Socio-Economic Deprivation Index (SEDI). Descriptive, factorial, and inferential statistical analyses were conducted.
Results: In the cultural adaptation, involving 17 participants (52.9% female and 64.7% aged ≥64 years), there was no need for linguistic changes, nor was there a significant difference in test-retest reliability, p=0.066. In the validation study, involving 222 patients (53.6% male and 71.1% aged 65 or older), the APTC demonstrated good reliability (Cronbach’s α=0.743) and an intra-class correlation coefficient of 0.716, with four components accounting for 60.7% of the total variance. In the convergent validation, a moderate positive and significant correlation of APTC with PAID-5 was found (ρ=0.300, p<0.001), and a very weak and non-significant negative correlation (ρ=-0.113, p=0.092) between the APTC sum and the SEDI value. The APTC total did not vary significantly according to sex (p=0.377), family type (p=0.242), monthly income (p=0.064), and academic background (p=0.518). The APTC score (p=0.023) and the SEDI score (p=0.026) were significantly different according to age group, both with higher values in those ≤64 years.
Discussion: The APTC encourages conversation between the general and family medicine doctors and the patient about the patient’s beliefs, attitudes, and difficulties regarding the management of multiple medications for a patient with multimorbidity, specifically diabetes.
Conclusion: It was possible to adapt and validate the ACTS questionnaire for European Portuguese, the APTC, with good psychometric qualities.
Downloads
References
1. Sociedade Portuguesa de Diabetologia. Diabetes: factos e números – O ano e 2019, 2020 e 2021 (relatório anual do Observatório Nacional da Diabetes). Lisboa: SPD; 2023.
2. Cicek M, Buckley J, Pearson-Stuttard J, Gregg EW. Characterizing multimorbidity from type 2 diabetes: insights from clustering approaches. Endocrinol Metab Clin North Am. 2021;50(3):531-58.
3. Kadam UT, Roberts I, White S, Bednall R, Khunti K, Nilsson PM, et al. Conceptualizing multiple drug use in patients with comorbidity and multimorbidity: proposal for standard definitions beyond the term polypharmacy. J Clin Epidemiol. 2019;106:98-107.
4. Remelli F, Ceresini MG, Trevisan C, Noale M, Volpato S. Prevalence and impact of polypharmacy in older patients with type 2 diabetes. Aging Clin Exp Res. 2022;34(9):1969-83.
5. Prazeres F, Santiago L. Multimorbidity in primary care in Portugal (MM-PT): a cross-sectional three-phase observational study protocol. BMJ Open. 2014;4(2):e004113.
6. İnci H. Evaluation of multiple drug use in patients with type 2 diabetes mellitus. Diabetol Int. 2021;12(4):399-404.
7. García-Pérez LE, Alvarez M, Dilla T, Gil-Guillén V, Orozco-Beltrán D. Adherence to therapies in patients with type 2 diabetes. Diabetes Ther. 2013;4(2):175-94.
8. Simões PA, Santiago LM, Simões JA. Prevalence of polypharmacy in the older adult population within primary care in Portugal: a nationwide cross-sectional study. Arch Med Sci. 2020;20(4):1118-27.
9. Carls G, Huynh J, Tuttle E, Yee J, Edelman SV. Achievement of glycated hemoglobin goals in the US remains unchanged through 2014. Diabetes Ther. 2017;8(4):863-73.
10. Adu MD, Malabu UH, Malau-Aduli AE, Malau-Aduli BS. Enablers and barriers to effective diabetes self-management: a multi-national investigation. PLoS One. 2019;14(6):e0217771.
11. Giugliano D, Maiorino MI, Bellastella G, Esposito K. Clinical inertia, reverse clinical inertia, and medication non-adherence in type 2 diabetes. J Endocrinol Invest. 2019;42(5):495-503.
12. Bailey CJ, Kodack M. Patient adherence to medication requirements for therapy of type 2 diabetes. Int J Clin Pract. 2011;65(3):314-22.
13. Silva GG, Tambury RL, Santos TE, Amorim AT. Não adesão ao tratamento farmacológico por pacientes diabéticos [Non-adherence to pharmacological treatment by diabetic patients]. Rev Psicol. 2022;16(61):141-54. Portuguese
14. Gao Y, Xiao J, Han Y, Ji J, Jin H, Mawen DG, et al. Self-efficacy mediates the associations of diabetes distress and depressive symptoms with type 2 diabetes management and glycemic control. Gen Hosp Psychiatry. 2022;78:87-95.
15. Luzuriaga M, Leite R, Ahmed H, Saab PG, Garg R. Complexity of antidiabetic medication regimen is associated with increased diabetes-related distress in persons with type 2 diabetes mellitus. BMJ Open Diabetes Res Care. 2021;9(1):e002348.
16. Pereira CS, Santiago LM, Silva IR, Ferreira P. Validation and cultural adaptation of the Problem Areas in Diabetes-5 (PAID-5) scale to European Portuguese. Acta Med Port. 2024;37(1):36-41.
17. Santiago LM, Simões JA, Vale M, Faria E, Ferreira PL, Rosendo I. Auto perceção do desempenho da medicina centrada na pessoa em medicina geral e familiar: criação de um instrumento de medição [Self-awareness of performing patient-centered medicine in general practice/family medicine: development of a measurement scale]. Acta Med Port. 2020;33(6):407-14. Portuguese
18. Brooks AD. Patient-centered care in type 2 diabetes mellitus. In: ACSAP Endocrinologic/Rheumatologic Care. ACSAP; 2016. p. 7-33.
19. Stack RJ, Noyce PR, New JP, Gibson M, Elliott RA, Bundy C. The Attitudes about Complex Therapy Scale (ACTS) in type 2 diabetes and cardiovascular disease: development, validity and reliability. Int J Diabetol Vasc Dis Res. 2015;3(9):130-6.
20. Tsang S, Royse CF, Terkawi AS. Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine. Saudi J Anaesth. 2017;11(Suppl 1):S80-9.
21. Tabachnick BG, Fidell LS. Using multivariate statistics. 7th ed. New York: Pearson; 2018. ISBN 9780134790541
22. Ribeiro AI, Mayer A, Miranda A, Pina MF. The Portuguese version of the European Deprivation Index: an instrument to study health inequalities. Acta Med Port. 2017;30(1):17-25.
23. Taber KS. The use of Cronbach’s alpha when developing and reporting research instruments in science education. Res Sci Educ. 2018;48(6):1273-96.
24. Tabachnick BG, Fidell LS. Using multivariate statistics. 6th ed. Boston: Pearson; 2012. ISBN 9780205849574
25. Pett MA, Lackey NR, Sullivan JJ. Making sense of factor analysis. Thousand Oaks: Sage; 2011. ISBN 9781412984898
26. Instituto Nacional de Estatística. Censos 2021: resultados definitivos – Portugal. Lisboa: INE; 2022. ISBN 9789892506197
27. Vieira JF, Santos P. Medication adherence in type 2 diabetes mellitus patients: a cross-sectional study. Rev Port Med Geral Fam. 2020;36(2):104-12.
28. Salvado NA. Adesão terapêutica numa população diabética atendida na Unidade de Diabetes do Hospital Amato Lusitano em Castelo Branco [dissertation]. Covilhã: Departamento de Ciências Médicas, Universidade da Beira Interior; 2012. Available from: http://hdl.handle.net/10400.6/1109
29. Silva I, Pais-Ribeiro J, Cardoso H. Adesão ao tratamento da diabetes mellitus: a importância das características demográficas e clínicas [Diabetes mellitus treatment adherence: the relevance of demographic and clinical characteristics]. Rev Enf Referência. 2006:II(2):34-41. Portuguese
30. Correia CI. Adesão ao regime terapêutico na pessoa com diabetes mellitus tipo 2: a importância da educação terapêutica [dissertation]. Viseu: Escola Superior de Enfermagem de Viseu/Instituto Politécnico de Viseu; 2014. Available from: http://hdl.handle.net/10400.19/2583
31. Rodrigues MC. Diabetes mellitus: percepção da doença e adesão ao tratamento [dissertation]. Covilhã: Faculdade de Ciências Sociais e Humanas, da Universidade da Beira Interior; 2015. Available from: http://hdl.handle.net/10400.6/6166
32. Ladeiro F, Magalhães AC, Costa D, Vidal-Castro J. Medida de adesão terapêutica nos idosos: um estudo em três Unidades de Cuidados de Saúde Personalizados [Measurement of therapeutic adherence in the elderly: a study in three Primary Health Care Centres]. Gaz Med. 2019;6(2):67-73. Portuguese
33. Mó RM. Adesão à terapêutica no idoso polimedicado e fatores de não adesão [dissertation]. Covilhã: Faculdade de Ciências da Saúde, da Universidade da Beira Interior; 2020. Available from: http://hdl.handle.net/10400.6/10650
34. Camarneiro AP. Therapeutic adherence: contributions to understanding and intervention. Rev Enf Referencia. 2021;5(7):1-8.
35. Delgado AB, Lima ML. Contributo para a validação concorrente de uma medida de adesão aos tratamentos [Contribution to concurrent validity of treatment adherence]. Psicol Saúde Doenc. 2001;2(2):81-100. Portuguese
36. Cabral AC, Moura-Ramos M, Castel-Branco M, Fernandez-Llimos F, Figueiredo IV. Cross-cultural adaptation and validation of a European Portuguese version of the 8-item Morisky medication adherence scale. Rev Port Cardiol. 2018;37(4):297-303.
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Portuguese Journal of Family Medicine and General Practice
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
The authors will assign to the RPMGF the sole right to publish and distribute the content of the manuscript specified in this declaration via physical, electronic, broadcasting or any other medium that may come into existence. They also grant the RPMGF the right to use and exploit this manuscript, in particular by assigning, selling or licensing its content. This permission is permanent and takes effect from the moment the manuscript is submitted, has the maximum duration allowed by applicable Portuguese or international law and is of worldwide scope. The authors further declare that this assignment is made free of charge. If the RPMGF informs the authors that it is not going to publish their manuscript, the exclusive assignment of rights ceases forthwith.
The authors authorise the RPMGF (or any entity it may appoint) to act on their behalf when it believes that copyright may have been infringed.
