ORIGINAL ARTICLE

Validation of the Asthma Quality of Life Questionnaire

(AQLQ–UK English Version) in Indian Asthmatic Subjects
Sunil K. Chhabra and Shivu Kaushik

Department of Cardiorespiratory Physiology, Clinical Research Centre, Vallabhbhai Patel Chest Institute,
University of Delhi, Delhi, India

ABSTRACT
Background. The Asthma Quality of Life Questionnaire (AQLQ) has been shown to have strong
measurement properties. Quality of life instruments need to be validated under local conditions
before these can be accepted for application in that community. The AQLQ has not been
formally validated in India.
Objectives. To measure the evaluative and discriminative properties of the AQLQ (UK English
version) in Indian asthmatics.
Methodology. Thirty-eight adult patients with asthma underwent spirometry and completed
the AQLQ and the Asthma Control Questionnaire (ACQ), administered by an interviewer.
Standard treatment was given for four weeks during which daytime and nocturnal symptoms
of asthma, and use of rescue medication were recorded in diaries. The questionnaires were
administered again at the end of four weeks and spirometry was repeated.
Results. The total and domain-wise scores of AQLQ improved in patients whose control of
asthma improved during treatment. It had good reproducibility with no changes in scores in
patients whose condition remained stable, and also high intraclass correlation coefficients for
the total and domain-wise scores in these patients. Significant correlations were found between
the changes in AQLQ scores and in ACQ scores confirming the longitudinal construct validity.
The symptoms domain score of the AQLQ was related significantly to the patient diary-
recorded scores of cough, sputum and nocturnal asthma. Cross-sectional construct validity of
AQLQ was established by demonstrating significant correlation of total, and symptoms and
emotions domain scores with the ACQ scores.
Conclusions. It was concluded that the AQLQ (UK English version) has sufficiently acceptable
evaluative and discriminatory properties in Indian subjects and is therefore a valid instrument
for quality of life measurements in clinical and research studies in asthmatics in Indian patients.

Key words: Asthma, Health-related quality of life, Asthma quality of life questionnaire, Asthma control
questionnaire.

[Indian J Chest Dis Allied Sci 2005; 47: 167-173]

INTRODUCTION and social spheres of a patient’s life. Effec-

tiveness of asthma treatment has traditionally
Asthma is a disease that can result in varying been assessed by measuring the change in
degrees of restriction in the physical, emotional clinical outcome parameters such as expiratory
[Received: January 21, 2004; accepted after revision: June 21, 2004]
Correspondence and reprints request: Dr S.K. Chhabra, Professor and Head, Department of Cardiorespiratory
Physiology, Clinical Research Centre, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi-110 007, India;
Tele.: 91-11-27667102; Telefax: 91-11-27667420; E-mail: <skchhabra@mailcity.com>.
168 Asthma Quality of Life
flow rates, symptoms and the need for other
medications. It has been assumed that if one or
more of these indices has improved, then the
patient’s health-related quality of life must have
improved. This may not be true. Conversely, a
patient may feel and function better, but this
may not be captured by the conventional clinical
outcomes. Assessment of disease-specific
quality of life in clinical trials has gained wide-
spread acceptance in the last decade because of
an increased awareness of its importance as an
independent outcome measure. This has been
further facilitated by the development of
instruments with strong measurement
properties for assessing quality of life1,2.
Among the various instruments available,
Juniper's Asthma Quality of Life Questionnaire
(AQLQ) has been tested extensively. Several
independent studies have shown that it has
strong measurement properties, both as an eva-
luative and as a discriminative instrument3-8. It
has been translated into various languages.
Instruments to measure the asthma-specific
health-related quality of life (HRQoL) have not
been developed in India. Therefore, for any
study on quality of life in Indian patients with
asthma, the instruments available in other
countries will have to be used. Quality of life is
likely influenced, besides by disease severity
and its treatment, by environment, personal
socio-economic and cultural factors. These
factors would vary from region to region and
from country to country. Further, the language
used in a quality of life instrument may have
different meanings in different populations.
Therefore, an instrument must be validated
under local conditions before it can be accepted
for application in that population. In the absence
of any indigenous instrument to measure
quality of life, there is a need to evaluate
whether the available Asthma Quality of Life
Questionnaire (AQLQ) instrument is suitable
for the Indian population. The present study
was carried out with this aim. The UK English
version of AQLQ was used, as a Hindi
translation had not been developed at the time
when this study was carried out.
S.K. Chhabra and S. Kaushik
MATERIAL AND METHODS
Subjects
Both male and female patients diagnosed to
have bronchial asthma, in the outpatient clinic
of the Clinical Research Center, Vallabhbhai
Patel Chest Institute, Delhi, were included in the
study. The diagnosis was established on the
basis of characteristic symptoms and
demonstration of reversibility of airways
obstruction (post-bronchodilator increase of 200
ml and 12% over baseline in FEV 1 ) as
recommended in the Expert Panel Report9 of the
National Institutes of Health, USA. Informed
consent was obtained from all the patients. The
inclusion criteria was : age group 15-40 years, no
other concurrent pulmonary or systemic
disease; relatively stable clinical state but
currently symptomatic; ability to understand
and respond to the English language. Patients
were excluded if they had a history of smoking
(>10 pack years), presence of previous lesions or
history of pulmonary tuberculosis or any other
respiratory disorder, any other chronic systemic
disease that may affect quality of life such as
diabetes, hypertension, coronary artery disease,
arthritis or were pregnant or lactating (for
females), etc.
Study design
A detailed history was taken from all the
subjects. Baseline spirometry was carried out in
all the subjects. Maximum expiratory flow
volume curves were obtained on a dry rolling-
seal spirometer (Benchmark Lung Function
machine-PK Morgan, UK) according to the
American Thoracic Society recommendations
for spirometry 10. The highest FVC and FEV 1
were selected. Regression equations for lung
function for Indian adults were used to calculate
percent-predicted values11.
The following assessments were carried out
at the time of inclusion into the study:
(i) Control of asthma : The degree of control
was assessed using the Asthma Control
Questionnaire (ACQ) 12 . The questionnaire
includes questions pertaining to five symptoms
2005; Vol. 47 The Indian Journal of Chest Diseases & Allied Sciences
considered most important for assessing asthma
control. In addition there is a question on short-
acting beta 2-agonist use and another on FEV1%
predicted. Patients recalled their experiences
during the previous seven days and responded
to each question using a seven-point scale. The
items are equally weighted and the ACQ score is
the mean of the seven items and therefore
between 0 (well-control) and 6 (extremely
poorly controlled).
(ii) Asthma quality of life questionnaire 3
(interviewer-administered version): The AQLQ has
32 questions, the first five of which are patient-
specific activities. At the first visit each patient
selects the five activities in which he or she has
been troubled the most by asthma during the
previous two weeks. These activities are
retained throughout the study for subsequent
tests. Patients respond to each question on a
seven-point scale and recall their experiences
during the previous two weeks. Results are
expressed as scores for each of four domains
(symptoms-12 questions, activities-11 questions,
emotional function-5 questions and environ-
mental exposure-4 questions) and as an overall
score. The total and the domain scores range
from 1 to 7 with higher scores indicating a better
quality of life.
After initial assessment and administration of
the study questionnaires, the patients were
prescribed appropriate treatment as per the
severity of asthma9. This consisted of inhaled
corticosteroids (budesonide: 400-800 µg/day or
fluticasone propionate: 250-500 µg/day) and if
required inhaled long-acting bronchodilators
(salmeterol: 50-100 µg/day or formoterol: 12-24
µg/day). Inhaled salbutamol (200 µg per dose,
=2 puffs) was prescribed as rescue medication.
All drugs advised to patients were in the form
of metered dose inhalers. The patients were
provided diaries to record daytime symptoms
(cough, phlegm, breathlessness/wheezing),
nocturnal symptoms and use of rescue
medication. The scores were graded from none
(0) to mild (1), moderate (2) and severe (3). The
patients were assessed again at the end of four
weeks when the AQLQ and ACQ question-
naires were administered. Diary scores were
noted. Spirometry was repeated.
169
Improvement in clinical state of asthma after
four weeks of treatment was defined as an
increase in the ACQ score of 0.5 or more14. At the
end of four weeks, patients who showed an
improvement were assigned to Group A and
those who showed no change in ACQ, to Group
B. No patient showed a worsening.
Statistical analysis
Statistical analysis was carried out with the
help of SPSS 11.5 and Graphpad Prism 3.0 for
windows. Continuous variables were compared
using unpaired/paired student’s t test.
Validation of the AQLQ was done by
measurement of its evaluative (responsiveness
and longitudinal construct validity) and
discriminative (reproducibility and cross-
sectional construct validity) properties16.
Evaluative properties
(i) Responsiveness : This is the ability of the
questionnaire to detect changes in clinical status
even if these are small. The responsiveness of
the questionnaire was determined in two ways,
firstly by comparing the scores between the
patients who improved (Group A) and those
who remained stable (Group B) using the
unpaired ‘t’ test and, secondly, by the ability of
the questionnaire to detect statistically
significant changes in patients who improved
(Group A) using the paired ‘t’ test.
(ii) Longitudinal construct validity: Longitu-
dinal construct validity was evaluated by
correlating within-subject changes in quality of
life scores during the four weeks observation
period with within-subject changes in other
indices of clinical asthma severity, i.e. ACQ
scores, FEV1 and the diary scores.
Discriminative properties
(i) Reliability: This is the ability of the
instrument of give reproducible results when
the clinical state is stable. Reliability of the
instruments was determined from the data of
patients who remained stable (Group B) between
baseline and four weeks. The scores were
compared on the two occasions (paired ‘t’ test)
170 Asthma Quality of Life S.K. Chhabra and S. Kaushik

and changes not significant were taken as an Table 2 shows the changes in AQLQ scores in
indicator of reproducibility. Further reliability the two groups. Except for the environmental
analysis was carried out by calculating the domain scores, the total and other domain
intraclass correlation coefficient for total and scores were significantly different, being higher
domain scores. Intraclass correlation coefficient in Group A patients, indicating an improved
was calculated as a measure of agreement quality of life. All the scores showed a mean
within cases using the reliability analysis change greater than one, that represents a
module of SPSS 11.5 software. moderate change in the quality of life17.
(ii) Cross sectional validity: It is the ability of the
Table 2. Comparison of changes in AQLQ total and
questionnaire to determine whether between-
domain scores in the two groups of patients
patients differences in quality of life truly reflect
differences in their clinical state. Cross sectional ∆ AQLQ Group A Group B
validity was evaluated by correlating quality of ∆ Total Score 1.46 ± 0.89* 0.37 ± 0.98
life scores at baseline with other measures of ∆ Symptoms 1.82 ± 1.11** 0.00 ± 1.25
asthma severity i.e. ACQ scores and FEV 1% ∆ Activity 1.41 ± 1.10* 0.25 ± 0.46
predicted. ∆ Emotional 1.19 ± 1.03+ 0.28 ± 1.13
∆ Environment 1.31 ± 1.46ns 0.62 ± 1.51
∆: Change; *:p<0.05; **:p<0.01; +:p<0.02; ns:p>0.05.
RESULTS

Patient characteristics 7
AQLQ Domain Scores Mean ± SD

6 **
A total of 38 patients (21 males and 17 females) **
** **
were included in the study. Thirty subjects 5 **
completed the study. The reason for the eight
subjects dropping out from the study was not 4

known. Thus, data from 38 patients was used for 3

cross-sectional construct validity analysis while
that from 30 patients was used for analysis 2

where two sets of data were required. The chara- 1

cteristics of the patients are shown in table 1.
0
0 wk 4 wk
Table 1. Patient’s characteristics Total Symptoms Activity Environment Emotional

Patient characteristics Description Figure 1. AQLQ total and domain scores at 0 week
and at four weeks in Group A patients.
Age (yrs) Mean±SD 26.89±8.24
Sex (n) Figure 1 shows the AQLQ total and domain
Males/Females 21/17
scores at 0 wk and at 4 wk in Group A patients.
Severity of Asthma (n) The scores showed a significant increase
Mild persistent 8 indicating an improved quality of life. The mean
Moderate persistent 15
total score on the second visit was 5.73 ± 0.77
Severe persistent 15
compared to 4.27 ± 0.78 at 0 wk (p<0.0001).
Domain-wise, the scores at 0 and 4 wk were,
Evaluative properties respectively; symptoms: 4.16±0.70 and 5.99±
0.90, p<0.0001; activities: 4.23±1.01 and
Responsiveness
5.64±0.85, p<0.0001; emotional: 4.60±0.89 and
Twenty-one patients improved after 5.80±1.05; p<0.0001; environment: 4.20±1.53 and
treatment and were assigned to Group A. Nine 5.51±1.15, p<0.001. This improvement in quality
patients whose control status remained of life scores in Group A was associated with an
unchanged were assigned to Group B. improvement in lung function indices. The FEV1
2005; Vol. 47 The Indian Journal of Chest Diseases & Allied Sciences 171

improved to 2.97±0.78L on the 2nd visit 8

AQLQ Domain Scores Mean ± SD

compared to 2.18±0.46 on the 1st visit 7
ns ns
(p<0.0001). The FVC on the 2nd visit was ns
6 ns
3.99±0.83L that was significantly greater than ns
the baseline value of 3.56±0.63L (p<0.01). 5

4
Longitudinal construct validity 3

Longitudinal construct validity correlations 2

are shown in the table 3. There were significant
correlations between the changes in quality of
life scores and the ACQ scores. However, no
significant correlations were found between the
changes in quality of life scores and other
indices of clinical asthma i.e. change in FEV1 and
the FEV1% predicted. Significant correlations
were also found between the symptoms domain
of the AQLQ and the patient diary recorded
scores of cough, sputum and nocturnal asthma.
No correlations were found between changes in
quality of life and beta agonist use scores during
the four weeks.
Discriminative properties
Reliability
Figure 2 shows the total and domain scores of
AQLQ in patients of Group B at 0 and 4 wks. The
mean total score at 4 wks was 5.20±1.07 com-
pared to 4.83 ± 0.87 at 0 wk (p>0.05). Domain-
1
0
Total
0wk
Symptoms Activity
4wk
Environment Emotional
Figure 2. AQLQ total and domain scores at 0 week
and at four weeks in Group B patients.
wise, the scores at 0 and four weeks were,
respectively; symptoms: 5.25±1.21 and
5.25±1.76, p>0.05; activities: 4.99±1.28 and
5.25±1.21, p>0.05; emotional: 5.04±1.17 and
4.75±1.49, p>0.05; environment: 3.99±1.20 and
4.61±2.16, p>0.05. The intraclass correlation
coefficients for total and domain scores were as
follows: total, 0.71; symptoms, 0.81; activities,
0.96; emotional, 0.79; environment, 0.76.
Cross-sectional construct validity
Cross-sectional construct validity correlations
are shown in table 4. There were significant
correlations between total scores and the

Table 3. Longitudinal construct validity of asthma quality of life questionnaire

∆ Symptoms ∆Activity ∆Emotional ∆Environment Total
∆FEV1 –0.083 –0.080 –0.067 0.103 0.010
∆FEV1% predicted –0.017 –0.023 0.047 0.187 0.108
∆ACQ –0.631** –0.512** –0.461* –0.272 0.583**
Diary Scores
Cough 0.363* 0.277 0.750 0.736 0.331
Breathlessness 0.353 0.193 0.09 0.020 0.161
Sputum 0.450* 0.025 0.148 0.112 0.283
Nocturnal asthma 0.455* 0.124 0.148 0.112 0.237
Beta-2 agonist score 0.298 0.266 0.222 0.283 0.277
∆: Change; *:p<0.05; **:p<0.01.

Table 4. Cross sectional construct validity of asthma quality of life questionnaire

Symptoms Activity Emotional Environment Total
FEV1% predicted 0.128 –0.176 0.323 0.228 0.176
ACQ –0.753** –0.246 –0.522** –0.303 –0.625**
**:p<0.01.
172 Asthma Quality of Life
symptoms and emotions domain scores of the
AQLQ and the ACQ scores. The strongest
correlation was seen between the symptom
domain of the AQLQ and the ACQ score. On the
other hand there was no significant relationship
with the FEV1% predicted.
All of our patients considered the questions
in the questionnaires to be relevant to their
asthmatic condition and there was apparently
no difficulty in understanding of any of the
questions.
DISCUSSION
The present study shows that UK-English
version of Juniper ’s Asthma Quality of Life
Questionnaire (AQLQ) has sufficiently accep-
table evaluative and discriminatory properties
for Indian asthmatic subjects and is therefore a
valid instrument for quality of life
measurements in clinical and research studies in
asthmatics in India.
In comparison to the nine stable patients,
twenty-one asthmatic subjects in our study who
improved on treatment showed an impro-
vement in the AQLQ total scores and all other
domains of the AQLQ except the environment
domain. All the subjects who showed improve-
ment had an increase in the mean total scores by
more than one, which is suggestive of a mode-
rate change in quality of life16. When within-
subjects changes were examined in the impro-
ved group of patients, improvement was seen in
both the total scores as well as all the domains of
the AQLQ. However in stable patients, there
was no change in total or domain-wise quality
of life scores. These observations on the respon-
siveness of the AQLQ are in agreement with
other studies 17. No change in quality of life
scores in stable patients in our study shows that
the questionnaire had good reproducibility.
In longitudinal correlations, positive relation-
ships were found between changes in AQLQ
and ACQ scores. The strongest correlation was
found with the symptoms domain of the AQLQ
(r=0.631). The symptoms domain of the AQLQ
also showed significant correlations with the
diary scores of cough, expectoration and
S.K. Chhabra and S. Kaushik
nocturnal asthma. There were no correlations
between spirometric indices i.e. ∆FEV 1
(∆= Change) and ∆FEV1% predicted and total or
domain-wise scores of AQLQ. The strong
correlation between ∆AQLQ scores and the
∆ACQ scores is understandable as the ACQ
evaluates the control over the past one week
and the patients with good control should have
better AQLQ scores and more so in the
symptom domain of the AQLQ as five of the
seven questions in the ACQ pertain to
symptoms. The poor correlation with FEV1 can
also be explained as FEV1 is a single measure-
ment in time, and in the natural course of any
asthmatic patient, there are swings in FEV1. The
AQLQ assesses the patient’s state over the
previous two weeks and thus may not correlate
well with the lung function. The correlations
between changes in scores of AQLQ and the
∆ACQ were stronger than with the diary scores.
Juniper et al 3 in their previous study have
reported more or less similar results.
In the absence of a gold standard, validity of
a questionniare may be established by showing
correlations between the questionnaire and
other related outcomes (cross-sectional
construct validity). This was done by relating
the total and the domains scores of AQLQ to
clinical asthma severity i.e. ACQ and FEV 1%
predicted. We found moderately significant
correlations between the ACQ and some of the
domains and the total scores of AQLQ (r=0.522
to 0.753). No correlation was seen with the
FEV 1% predicted. It is known that there is a
wide range of HRQoL scores for a given level of
lung function18. Degree of airways obstruction is
only one of the possible determinants of quality
of life. Thus, it can be argued that FEV 1 alone
should not be used to define subjects into
various categories of severity of asthma.
As a validated Hindi version of AQLQ was
not available at the time we carried out this
study, the UK English version was used. Hence,
knowledge of English language was one of the
inclusion criteria. In India, people who are
fluent in English are generally better-off
economically. Therefore, extrapolating these
results to all social and economic classes would
be difficult. However, given its acceptable
2005; Vol. 47 The Indian Journal of Chest Diseases & Allied Sciences
discriminative and evaluative properties
observed in the present study, the AQLQ needs
to be studied in a wider spectrum of patients
with diverse educational and economic
backgrounds. A Hindi version of the AQLQ has
recently been developed and such studies
should be possible now. Leidy et al19 described
the AQLQ as a useful indicator of health related
quality of life in low income asthmatics.
To conclude, the AQLQ developed by Juniper
et al3 has acceptable evaluative and discrimi-
natory properties for use in Indian asthmatic
patients.
ACKNOWLEDGEMENTS
The authors wish to thank Prof. Elizabeth Juniper
for her kind permission to use the UK English
version of the AQLQ.
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174 The Indian Journal of Chest Diseases & Sciences 2005; Vol. 47

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