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Nicotine dependence was assessed through the nicotine de- (doubly labeled water), estimates of physical fitness (heart rate), or
pendence module of the Composite International Diagnostic In- measures of physical motion by accelerometers. 57 A beneficial
41
terview. The Composite International Diagnostic Interview is a trait of the questionnaire is that it does not influence the behavior
comprehensive and standardized instrument to assess the presence being measured, and although less precise than the objective
of nicotine dependence in the past year and a lifetime history of measures, it estimates activity relative to others in the population.
nicotine dependence. It is reported to provide reliable and valid The questionnaire may range from one item to an array of ques-
psychiatric diagnosis of nicotine dependence based on the Inter- tions covering a wide range of occupational and leisure activities,
national Classification of Diseases (ICD-10) and the Diagnostic and and may cover varying time intervals. A compilation of physical
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Statistical Manual of Mental Disorder (DSM-IV). 42 activity questionnaires and a review of their psychometric properties
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was published, providing an excellent resource for anyone wishing
Questionnaires to measure exercise adherence. 58 In selecting a questionnaire, the
Questionnaires are available to assess adherence across multiple be- investigator must consider characteristics of the population, such as
haviors. Although there are numerous scales available for assessment gender, age, culture, and the outcome of interest. Most of the ac-
of eating and exercise behaviors, few exist for medication-taking be- tivity questionnaires were developed with men’s activities in mind
havior. The Morisky scale, first published in 1986, has been adapted making them less sensitive to differences in physical activity levels
by several investigators and used as a paper-and-pencil question- in women. 57 The Kaiser Physical Activity Survey, which includes
naire in several populations, including those being treated for hy- questions on household/care giving activities, is available to meas-
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percholesterolemia, rheumatoid arthritis, and HIV. This scale, for ure physical activity in women. The 7-day Physical Activity Recall
which adequate psychometric properties have been reported, was and the Paffenbarger Physical Activity Questionnaire are widely
used recently in a study of medication adherence among older used for various groups including patients in cardiac rehabilitation
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Chinese immigrants 43 and patients taking cardiovascular med- programs, male veterans, 61,62 individuals in the National Weight
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ications. 44,45 Shalansky et al. 45 recommended rewording the Control Registry, and adults with a body mass index greater than
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questions, increasing the number of items, and the use of graded 27. The Community Healthy Activities Model Program is a valid
response options to improve the scale’s consistency. Rottlaender and reliable questionnaire to estimate physical activity among mid-
46
et al. used the scale and found that 83% of the patients reported dle- and older-aged adults. 65
they were absolutely compliant to their medication regimen but The most common measure of nicotine dependence among cig-
the Morisky score indicated high adherence in only 52% of the arette smokers is the Fagerstorm Tolerance Questionnaire (FTQ), 66
sample. Similarly, the Morisky questionnaire revealed lower adher- which was designed to estimate the degree of nicotine dependence
ence rates than that measured by pill count. 47 in smoking. The Fagerstrom Test for Nicotine Dependence
Dietary adherence can be measured by several established (FTND) is a shortened version of FTQ that emphasizes cigarette
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questionnaires including the Connor Diet Habit Survey, the Eat- consumption and time to first cigarette after awakening. Recently,
ing Pattern Questionnaire, and food frequency questionnaires the Cigarette Dependence Scale (CDS-12) has been proposed as a
(FFQ). The first two questionnaires focus on fat intake and have good alternative to FTND for measuring nicotine dependence with
reported psychometric properties when used in cardiac and gen- better validity and internal consistency than FTND. 68
eral populations. 48,49 However, the FFQ is now the most com- In summary, questionnaires with a shorter time interval are less
monly used dietary measure to provide estimates of usual dietary vulnerable to recall bias and easier to validate with objective meas-
intake over time (typically 6 months to a year) in large epidemio- ures. However, using a shorter time frame reduces the likelihood
50
logical studies. FFQs include a list of foods with a frequency re- of obtaining a picture of usual behavior, because eating and exer-
sponse section to report how often and how much each food item cise patterns may vary by season. Reliability and validity are af-
was consumed. Examples of FFQ are the Harvard/Willett FFQ, fected by the person’s ability to store and retrieve information, and
National Cancer Institute’s Diet History Questionnaire (DHQ), by potential influence of the interviewer or respondent bias. 69,70
and the Fred Hutchinson FFQ. The Fred Hutchinson FFQ was
updated in 2001 and has a separate questionnaire for men and Diaries
women. The DHQ was recently updated in 2007 to reflect Daily diaries for food intake or exercise circumvent the bias of re-
changes in food availability. Both Fred Hutchinson FFQ and the call, but require training and cooperation of the patient or study
DHQ are available in English and Spanish. Although FFQs pro- participant, which limits its use to highly motivated, literate indi-
vide a relatively inexpensive and standardized way of collecting di- viduals. While diaries may be used as part of an intervention to
etary information, their major limitation is the number and types achieve awareness of one’s behavior, the focus here is on assessment
of items listed thereby reducing its utility among ethnic groups. 37 of adherence. Food and exercise diaries are often used periodically
It becomes very important for the FFQ to be culture-specific to and cover a 3- or 7-day period, including one nonwork or leisure
capture dietary intake of specific racial/ethnic groups. FFQs have day. Recording for extended periods (i.e., over 3 days) may reduce
been adapted and validated to assess the diet of diverse popula- accuracy, and the recording may begin to influence the recorder’s
tions, 51 US Chinese women, 52 South Asians in the UK, 53 and behavior. Several investigators 71–73 have used diaries to measure ex-
elderly populations of low socioeconomic status. 54 A regionally ercise and dietary adherence. Wickel 74 reported high convergent
specific FFQ has been developed for white and black adults resid- validity for the Bouchard activity diary with an accelerometry-
ing in the southern region of the United States. 55 based monitor. However, when comparing self-report (question-
Measurement of physical activity, which continues to receive naire) to doubly labeled water data, Walsh et al. 75 demonstrated
high priority in the public health field, has relied primarily on the that sedentary overweight women overreported their exercise in
questionnaire. 56,57 Exercise assessment questionnaires, which are comparison to normal weight control counterparts.
subjective measures, have been validated by objective measures of Issues of concern with self-report measures include response
physical activity, such as measures of total energy expenditure biases due to social desirability, deliberate and nondeliberate