Introduction
Chronic diseases put high pressure on patients, families, and society [1، 2]. According to the World Health Organization, nearly one in three adults globally suffers from multiple chronic diseases [3]. These diseases have negative impact on various aspects of life, including physical, emotional, and social aspects [4-7]. Challenges with managing chronic diseases lead to losing self-esteem in patients, and make them vulnerable to mental health problems such as depression and anxiety, as well as fatigue and decreased quality of life [3, 8-11]. When there is no specific treatment for chronic diseases, patients need to improve coping strategies to enhance their quality of life. According to studies, coping strategies have two types of adaptive and maladaptive. Adaptive coping is associated with a decrease in psychological distress [9], while maladaptive coping is associated with psychological pressure and impaired function [9, 12]. The Adaptive Coping with Disease (AKU) questionnaire was designed by Bussing et al. [13] to identify adaptive coping strategies for chronic diseases. This study aims to assess the psychometric properties of the Persian version of the AKU questionnaire for Iranian patients with chronic diseases.

Methods
After translating, the questionnaire was completed by 477 patients with chronic diseases referred to medical centers in Tehran, Iran in 2022. To determine convergent validity, 153 participants also completed Lazarus’ ways of coping questionnaire (WCQ) and the 36-item short form health survey (SF-36) questionnaires. The internal consistency was assessed using Cronbach’s alpha coefficient. Construct validity was evaluated using the confirmatory factor analysis (CFA), the calculation of the Average Variance Extracted (AVE) and Composite Reliability (CR) indices.

Results
The average age of participants was 39 years (SD=13.43). The results of CFA to evaluate construct validity are presented in Table 1.



The results of CFA confirmed the 6-factor structure of the Persian AKU questionnaire, but two items (6 and 19) were removed due to non-significant factor loadings (Figure 1).



The Persian AKU questionnaire demonstrated good internal consistency (α> 0.7), and acceptable composite reliability (CR>0.7) (Table 2). The Persian AKU scores exhibited significant correlations with the emotion-focused and problem-focused coping subscales of the WCQ (r=1 and 0.92, respectively; P<0.001), and with the physical health and mental health dimensions of the SF-36 (r=0.27 and 0.39, respectively; P<0.001), indicating good convergent validity.




Conclusion 
This study confirmed the validity and reliability of the Persian AKU questionnaire for Iranian patients with chronic diseases. It has good internal consistency and the CFA supported the 6-factor structure of the questionnaire, consistent with results of Bussing et al. [13,14]. However, two items (6 and 19) were removed. Considering the importance of the Item 19, it is recommended to exclude it only for diseases that do not require medication. An important finding of this study was the positive and significant correlation between the total AKU score and both emotion-focused and problem-focused coping domains of the WCQ. Existing research on coping styles has reported the link between emotion-focused coping strategies and reduced levels of adaptation and health-related quality of life [15]. However, our finding is against these results. For adaptation to chronic diseases, both emotion- and problem-focused coping strategies are needed. These strategies include therapeutic procedures to improve or control symptoms (problem-focused), as well as religious or spiritual coping strategies (emotion-focused) that help patients to accept challenging conditions caused by the disease and increase their tolerance levels [5, 13, 16]. Thus, problem-focused and emotion-focused strategies, when applied in the appropriate context, are both adaptive coping mechanisms. This finding is consistent with existing literature on the importance of emotion-focused strategies for chronic diseases [5, 17, 18].
The AKU score also showed a significant positive correlation with the physical and mental health domains of the SF-36, albeit it was at a weak to moderate level. This finding is consistent with the study by Bussing et al., who also reported a weak positive correlation between the AKU score and physical and mental health domains of the SF-12 [7]. It should be noted that, regardless of the extent to which people use adaptive coping strategies, a significant part of a person’s quality of life, especially in the physical aspect, is out of the person’s complete control, considering that there is no possibility of complete recovery, and is affected by the nature, severity, and course of the disease, and makes a person inevitably change her/his living conditions in line with her/his physical condition. Consequently, the person has to face a change in role and function in different areas of life and accept and adapt to it.
One of the strengths of this study was the relatively large sample size with a wide range of chronic diseases and age ranges. However, the results cannot be generalized to all patients in Iran. In the current study, participants included both patients requiring medication and those without such interventions. Therefore, the exclusion of the item 19, which is related to medication use and is a crucial item, may pose challenges. It is recommended that future studies investigate this issue again in patients with and without pharmacotherapy.

Ethical Considerations

Compliance with ethical guidelines
The research protocol was approved by the ethics committee of Iran University of Medical Sciences (code: IR.IUMS.REC.1399.950).

Funding
This study was funded by the Mental Health Research Center, Psychosocial Health Research Institute, Iran University of Medical Sciences.

Authors contributions
Conceptualization, methodology, validation: Sara Sobhani, Fahimeh Fathali Lavasani and Hojjatollah Farahani; Project administration: Sara Sobhani, Reihaneh Moniri and Arezoo Samadi; Formal analysis: Hojjatollah Farahani; Supervision: Fahimeh Fathali Lavasani; Investigation, writing – original draft: Sara Sobhani; Review & Editing: All authors.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank all the patients participated in this study as well as the personnel of Rasool-e Akram Hospital, Firouzgar Hospital, and Abadis Spine Clinic for their cooperation in the study. The authors also thank the Mental Health Research Center, Psychosocial Health Research Institute, Iran University of Medical Sciences for their financial support.



 

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