Acta Scientific Orthopaedics (ISSN: 2581-8635)

Research Article Volume 3 Issue 10

Transcultural Adaptation and Validation of the Arabic Version of the Compliance Questionnaire for Rheumatology

Nelly Raymond Ziadé1*, Ghada Abi Karam1, Nelly Salloum2 and Marouan Zoghbi3

1Rheumatology Department, Saint-Joseph University, Hotel-Dieu Hospital, Beirut, Lebanon
2Registered Nurse, ZClinic, Beirut, Lebanon
3Family Medicine Department, Saint-Joseph University, Beirut, Lebanon

*Corresponding Author: Nelly Raymond Ziadé, Rheumatology Department, Saint-Joseph University, Hotel-Dieu Hospital, Beirut, Lebanon.

Received: August 31, 2020; Published: September 25, 2020



Background: To date, the Compliance Questionnaire for Rheumatology (CQR) is the only self-reported adherence measure created for and validated in Chronic Inflammatory Rheumatic Diseases (CIRDs). However, it has not been validated in Arabic.

Aim: To translate, culturally adapt, and validate the CQR in Arabic.

Methods: Cross-sectional study, with a longitudinal component to test reliability, using the WHO guidelines: forward and back-translation, cognitive debriefing, and final validation with CIRDs patients (rheumatoid arthritis, spondyloarthritis, connective tissue disease, and Behcet’s disease).

Results: The CQR was translated and back-translated by two independent translators, and a cognitive debriefing was performed with 30 patients. For the final validation, 102 patients were included and found that the questionnaire was easy to complete (average time 4.8 minutes). The CQR was significantly associated with self-reported adherence. Test-retest reliability was high (ICC 0.94 (95% CI 0.85 to 0.98)), internal consistency was acceptable (Cronbach α of 0.704). The mean CQR score was 85.4% and was statistically associated with age.

Implications: The CQR was validated in Arabic and can be a useful tool in future clinical and research settings in the Arab world.

Keywords: Compliance; Adherence; Questionnaire; Rheumatoid Arthritis; Spondyloarthritis; Connective Tissue Diseases; Behcet’s Disease



  1. Goodacre LJ and Goodacre JA. “Factors influencing the beliefs of patients with rheumatoid arthritis regarding disease-modifying medication”. Rheumatology 43 (2004): 583-586.
  2. Harrold LR and Andrade SE. “Medication Adherence of Patients with Selected Rheumatic Conditions: A Systematic Review of the Literature”. Seminars in Arthritis and Rheumatism 38 (2009): 396-402.
  3. World Health Organization. “Adherence to Long-Term Therapies” (2003).
  4. Grijalva CG., et al. “Assessment of Adherence to and Persistence on Disease-Modifying Antirheumatic Drugs (DMARDs) in Patients With Rheumatoid Arthritis”. Medical Care 45 (2007): S66-S76.
  5. Roter DL and Hall JA. “Strategies for enhancing patient adherence to medical recommendations”. The Journal of the American Medical Association 271 (1994): 80.
  6. Hughes DA., et al. “The impact of non-compliance on the cost-effectiveness of pharmaceuticals: A review of the literature”. Health Economics 10 (2001): 601-615.
  7. Steiner JF and Prochazka AV. “The assessment of refill compliance using pharmacy records: Methods, validity, and applications”. Journal of Clinical Epidemiology 50 (1997): 105-116.
  8. Barber N. “Patients’ problems with new medication for chronic conditions”. Quality and Safety in Health Care 13 (2004): 172-175.
  9. Viller F., et al. “Compliance to drug treatment of patients with rheumatoid arthritis: a 3 year longitudinal study”. The Journal of Rheumatology 26 (1999): 2114-2122.
  10. Park DC., et al. “Medication adherence in rheumatoid arthritis patients: older is wiser”. Journal of the American Geriatrics Society 47 (1999): 172-183.
  11. Hobeika M., et al. “Adherence to systemic therapies for immune- mediated inflammatory diseases in Lebanon : a physicians ’ survey from three medical specialties”. Patient Preference and Adherence (2017): 939-945.
  12. Copher R., et al. “Physician perception of patient adherence compared to patient adherence of osteoporosis medications from pharmacy claims”. Current Medical Research and Opinion 26 (2010): 777-785.
  13. JR Curtis., et al. “Agreement between Rheumatologist and Patient-Reported Adherence to Methotrexate in a U.S. Rheumatoid Arthritis Registry”. The Journal of Rheumatology 43 (2016): 1027-1029.
  14. Geraldino-Pardilla., et al. “Association between hydroxychloroquine levels and disease activity in a predominantly Hispanic systemic lupus erythematosus cohort”. Lupus 28 (2019): 862-867.
  15. Marengo MF., et al. “Improving treatment adherence in patients with rheumatoid arthritis: what are the options?” International Journal of Clinical Rheumatology 10 (2015): 345-356.
  16. Chisholm MA., et al. “Patient factors associated with adherence to immunosuppressant therapy in renal transplant recipients”. American Journal of Health-System Pharmacy 62 (2005): 1775-1781.
  17. Hill J. “Adherence with drug therapy in the rheumatic diseases Part two: measuring and improving adherence”. Musculoskeletal Care 3 (2005): 143-156.
  18. De Klerk E., et al. “Development of a questionnaire to investigate patient compliance with antirheumatic drug therapy”. The Journal of Rheumatology 26 (1999): 2635-2641.
  19. De Klerk E., et al. “Patient compliance in rheumatoid arthritis, polymyalgia rheumatica, and gout. Erratum appears in”. The Journal of Rheumatology 2 (2003): 423.
  20. Hughes LD., et al. “A 5 item version of the Compliance Questionnaire for Rheumatology (CQR5) successfully identifies low adherence to DMARDs”. BMC Musculoskeletal Disorders 14 (2013): 286.
  21. Pedersini R., et al. “Validation Of The Compliance-Questionnaire-Rheumatology, A Behavior-Focused Predictive Adherence Questionnaire, With The Morisky Medication Adherence Scale”. Value Heal 17 (2014): A50.
  22. Choquette D., et al. “Prediction of non-adherence in patients with rheumatoid arthritis Data comparison between 0 and 6 months”. Annals of the Rheumatic Diseases 74 (2015): 245.
  23. Lee JY., et al. “Cultural Adaptation of a Compliance Questionnaire for Patients with Rheumatoid Arthritis to a Korean Version”. The Korean Journal of Internal Medicine 26 (2011): 28.
  24. Fernández-Avila D., et al. “Initial Validation of Compliance-Questionnaire- Rheumatology (CQR) In Patients with Rheumatoid Arthritis in BogotΆ, Colombia”. Annals of the Rheumatic Diseases 74 (2015): 974-975.
  25. Ometto F., et al. “Adherence in rheumatoid arthritis patients assessed with a validated Italian version of the 5-item Compliance Questionnaire for Rheumatology”. Clinical and Experimental Rheumatology 37 (2019): 915-922.
  26. Cinar FI., et al. “Cross-Cultural Adaptation, Reliability, and Validity of the Turkish Version of the Compliance Questionnaire on Rheumatology in Patients With Behçet’s Disease”. Journal of Transcultural Nursing 27 (2016): 480-486.
  27. Shetty R., et al. “Impact of Medication Adherence by Using Indian Version Compliance Questionnaire Rheumatology (Cqr) and Medication Adherence Report Scale (Mars) Tools on Quality of Life of Patients With Rheumatoid Arthritis”. Value Health 17 (2014): A385.
  28. Chardin J. Arab World (2004).
  29. World Health Organization Process of translation and adaptation of instruments (2014).
  30. Language Scientific Cognitive Debriefing Explained (2017).
  31. Marras C., et al. “Identification of patients at risk of non-adherence to oral antirheumatic drugs in rheumatoid arthritis using the Compliance Questionnaire in Rheumatology: an ARCO sub-study”. Rheumatology International 37 (2017): 1195-1202.
  32. De Klerk E., et al. “The Compliance-Questionnaire-Rheumatology Compared with Electronic Medication Event Monitoring: A Validation Study”. The Journal of Rheumatology 30 (2003): 2469-2475.
  33. Rauscher V., et al. “High degree of nonadherence to disease-modifying antirheumatic drugs in patients with rheumatoid arthritis”. The Journal of Rheumatology 42 (2015): 386-390.
  34. Salgado E., et al. “Spanish transcultural adaptation and validation of the English version of the compliance questionnaire in rheumatology”. Rheumatology International 38 (2018): 467-472.
  35. Mehat P., et al. “Medication Nonadherence in Systemic Lupus Erythematosus: A Systematic Review”. Arthritis Care and Research 69 (2017): 1706-1713.
  36. Arturi P., et al. “Adherence to treatment in patients with ankylosing spondylitis”. Clinical Rheumatology 32 (2013): 1007-1015.
  37. Hromadkova L., et al. “Drug compliance in patients with systemic scleroderma”. Clinical Rheumatology 31 (2012): 1577-1583.
  38. Garcia-Gonzalez A., et al. “Treatment adherence in patients with rheumatoid arthritis and systemic lupus erythematosus”. Clinical Rheumatology 27 (2008): 883-889.
  39. Wabe N., et al. “Factors associated with medication adherence in a longitudinal study of rheumatoid arthritis patients”. International Journal of Clinical Practice 73 (2019): 1-9.
  40. Salaffi F., et al. “Adherence to subcutaneous anti-TNFα agents in patients with rheumatoid arthritis is largely influenced by pain and skin sensations at the injection site”. International Journal of Rheumatic Diseases (2020): 1-8.
  41. Kelly A., et al. “Patients’ Attitudes and Experiences of Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis and Spondyloarthritis: A Qualitative Synthesis”. Arthritis Care and Research 70 (2018): 525-532.
  42. Raghunath S., et al. “Qualitative assessment of medication adherence in patients with rheumatic diseases on biologic therapy”. Clinical Rheumatology 38 (2019): 2699-2707.
  43. Zayed HS., et al. “Evaluation of treatment adherence in patients with Behçet’s disease: its relation to disease manifestations, patients’ beliefs about medications, and quality of life”. Clinical Rheumatology 38 (2019): 761-768.
  44. Zwikker HE., et al. “Perceived need to take medication is associated with medication non-adherence in patients with rheumatoid arthritis”. Patient Preference and Adherence 8 (2014): 1635-1645.
  45. Pasma A., et al. “Facilitators and barriers to adherence in the initiation phase of disease-modifying antirheumatic drug (DMARD) use in patients with arthritis who recently started their first DMARD treatment”. The Journal of Rheumatology 42 (2015): 379-385.
  46. Salgado E., et al. “Spanish transcultural adaptation and validation of the English version of the compliance questionnaire in rheumatology”. Rheumatology International 38 (2018): 467-472.


Citation: Nelly Raymond Ziadé., et al. “Transcultural Adaptation and Validation of the Arabic Version of the Compliance Questionnaire for Rheumatology".Acta Scientific Orthopaedics 3.10 (2020): 25-34.


Acceptance rate33%
Acceptance to publication20-30 days

Indexed In

News and Events

  • Certification for Review
    Acta Scientific certifies the Editors/reviewers for their review done towards the assigned articles of the respective journals.
  • Submission Timeline for Upcoming Issue
    The last date for submission of articles for regular Issues is May 30, 2024.
  • Publication Certificate
    Authors will be issued a "Publication Certificate" as a mark of appreciation for publishing their work.
  • Best Article of the Issue
    The Editors will elect one Best Article after each issue release. The authors of this article will be provided with a certificate of "Best Article of the Issue"
  • Welcoming Article Submission
    Acta Scientific delightfully welcomes active researchers for submission of articles towards the upcoming issue of respective journals.

Contact US