Alcohol and Alcoholism, 2020, 1–8

doi: 10.1093/alcalc/agaa061
Article

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Article

Psychometric Properties of the Person-Centered

Version of the Alcohol and Alcohol Problems
Perceptions Questionnaire (PC-AAPPQ)
Khadejah F. Mahmoud 1 ,*, Lauren Terhorst2 , Dawn Lindsay3 ,
Jenna Brager4 , Tamar Rodney5 , Michael Sanchez5 , Bryan R. Hansen5 ,
Christine L. Savage5 , J. Paul Seale6 , Ann M. Mitchell7 ,
J. Aaron Johnson8 , and Deborah S. Finnell 5
1
University of Pittsburgh, Graduate School of Public Health, Pittsburgh, PA 15213, USA , 2 University of Pittsburgh,
School of Health and Rehabilitation Sciences, Pittsburgh, PA 15219, USA , 3 Institute for Research, Education & Training
in Addictions, Pittsburgh, PA 15219, USA , 4 Life Bridge Health, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA ,
5
Johns Hopkins School of Nursing, Baltimore, MD 21205, USA , 6 Mercer University, School of Medicine, Department
of Family Medicine, Macon, GA 31206, USA , 7 University of Pittsburgh School of Nursing, Pittsburgh, PA 15261, USA ,
and 8 Augusta University, Department of Psychological Sciences and School of Graduate Studies, Institute of Public
& Preventative Health, Augusta, GA 30912, USA

*Corresponding author: University of Pittsburgh, Graduate School of Public Health, Pittsburgh, PA 15261,
USA. E-mail: kfm22@pitt.edu
Received 4 December 2019; Revised 5 June 2020; Editorial Decision 6 June 2020; Accepted 6 June 2020

Abstract
Aims: Given the importance of addressing provider attitudes toward individuals with unhealthy
alcohol use and the current emphasis on person-centered language to help decrease stigma and
mitigate negative attitudes, the aim of this study was to evaluate the psychometric properties of
a contemporary version of the Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ)
that uses person-centered language and addresses the spectrum of alcohol use.
Methods: The authors created a person-centered version of the AAPPQ (PC-AAPPQ) and conducted
a cross-sectional study of its psychometric properties in academic settings in the Northeastern
United States. The PC-AAPPQ was administered to 651 nursing students. Reliability analysis of the
new instrument was performed using the total sample. Only surveys with complete data (n = 637)
were randomly split into two datasets, one used for the exploratory factor analysis (EFA) (n = 310)
and the other for confirmatory factor analysis (CFA) (n = 327).
Results: Compared to all the models generated from the EFA, neither the original six-factor structure
nor the five-factor structure was superior to any of the other models. The results indicate that a
seven-factor structure with all 30 items is the best fit for the PC-AAPPQ.
Conclusions: The PC-AAPPQ represents a positive effort to modernize the four-decade-old AAPPQ.
This 30-item instrument, which adds one additional subscale, offers a means to assess providers’
attitudes using respectful wording that avoids perpetuating negative biases and reinforces efforts
to affirm the worth and dignity of the population being treated.

© The Author(s) 2020. Medical Council on Alcohol and Oxford University Press. All rights reserved. 1
2 Alcohol and Alcoholism, 2020

INTRODUCTION ‘individuals who drink alcohol’. A driving force for the emphasis
on person-first language has been to mitigate the stigma that may
Developed over four decades ago, the Alcohol and Alcohol Problems
be perpetuated by pejorative language. Terms such as ‘addict’, ‘alco-
Perception Questionnaire (AAPPQ) was conceptually developed to
holic’, ‘opioid addict’ and ‘substance abuser’ are associated with a
assess therapeutic attitudes of individuals working with persons with
greater negative bias. Impeding factors in the healthcare delivery for
alcohol problems (Cartwright, 1980). The measure was constructed
these patients can be attributed to inadequate education, training
with two main subscales: role security and therapeutic commitment.

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and support structures in working with this patient group (Van
Role security included items related to the adequacy of their knowl-
Boekel et al., 2013). Culturally appropriate language (i.e. person-
edge and skills in working with these clients (role adequacy) and
centered language) when communicating with patients is essential in
how appropriate it is to work with these clients (role legitimacy)
reducing stigma perceptions related to substance use among health-
(Cartwright, 1980). The therapeutic commitment included items
care providers (Wakeman, 2013) and was a driving need for this
related to motivation or willingness to work with the population,
revised AAPPQ measure. It seems critical that the AAPPQ, one of
self-esteem in the specific tasks and expectation of work satisfaction
the primary tools for measuring clinician attitudes toward individuals
(Gorman and Cartwright, 1991).
with unhealthy alcohol use, should provide a positive example in
Since the development of the AAPPQ, various versions were
using person-centered language to assess these attitudes and avoid
developed and used in a number of studies (Cartwright, 1980;
inadvertent use of language that demeans the population being
Anderson and Clement, 1987; Lightfoot and Orford, 1986; Hughes
treated. Thus, a modified version of the AAPPQ measure should
et al., 2008; Terhorst et al., 2013). The original AAPPQ with five-
utilize language that does not mistakenly bias respondents’ attitudes
factor structure was used in two studies, one administrated on
and perceptions or is otherwise not offensive to those completing the
a sample of 115 healthcare and addiction staff workers (nurses,
survey.
social workers, physicians, volunteers and directors of an alcoholism
In this study, the need to address stigmatizing language in the
treatment agency) (Cartwright, 1980) In that study, the AAPPQ
addiction field was also combined with the need to focus on using
subscales’ alpha coefficients ranged from α = 0.70 to α = 0.90
language that addresses the entire alcohol use continuum and not
(Cartwright, 1980). The second study was conducted on 48 social
limit it to alcohol use disorders or alcohol misuse. This decision was
workers and community psychiatric nurses (alpha coefficients that
made because of the need to highlight the importance of implement-
ranged from α = 0.75 to α = 0.95) (Lightfoot and Orford, 1986). A
ing of alcohol use preventive measures, a movement that began in the
later version combined the original five subscales with items related
1980s with the establishment of reliable screening tools for alcohol
to the extent to which they felt supported in their work with clients
use (Babor et al., 2007).
(role support) (Anderson and Clement, 1987). This later version
As the largest group of healthcare providers in the USA (more
was used by a number of investigators (Anderson and Clement,
than 4 million) (American Nurses Association, 2020), nurses, who
1987; Hughes et al., 2008). Anderson and Clement (Anderson and
are the frontline healthcare providers, can play an important role in
Clement, 1987) validated the developed AAPPQ six-factor structure
addressing harms associated with alcohol use within their workplace.
on 467 general practice physicians. The authors also created a shorter
Examining future nurses’ therapeutic attitudes toward alcohol use
version of the AAPPQ (10 items), in which they included 2 items
is key in designing educational interventions that can identify and
(those with the highest factor loading) from each of the original
target these negative attitudes before these nurses graduate and
AAPPQ 5 subscales (excluding role support) and correlated this
join the professional workforce. If we are to modify the measure
shorter version with the original AAPPQ (r = 0.78), which was later
to incorporate person-centered language as well as focus on the
used in a number of studies (Anderson and Clement, 1987; Anderson
alcohol use continuum, it is important to examine the psychometric
et al., 2003; Crothers and Dorrian, 2011). More recently and using
proprieties via factor analyses of this contemporary version of the
confirmatory techniques on undergraduate nursing students, a seven-
AAPPQ. Therefore, the purpose of this study was to conduct an
factor structure was established in which the original factor structure
exploratory and confirmatory factor analyses on a modified version
labels were retained and the new factor was named lack of confidence
of the AAPPQ that uses person-centered language and addresses the
(Terhorst et al., 2013). This study, which was conducted on under-
continuum of alcohol use.
graduate nursing students with limited alcohol-related professional
experience, also reported similar subscales’ internal consistencies
compared to the previous studies (α = 0.71 to α = 0.90) (Terhorst
METHODS
et al., 2013). However, in all these studies, the authors used the
original wording of the AAPPQ, which refers to the population as Study sample
‘drinkers’ and included outdated diagnostic terminology (i.e. alcohol Cross-sectional survey data were collected from seven cohorts of
dependence syndrome). The use of such terminology can contribute prelicensure nursing students enrolled in two schools of nursing in
to the negative attitudes of health professionals toward patients with the northeast and mid-Atlantic regions of the USA. Graduates of these
at-risk alcohol use, defined as any use that can increase a person’s risk programs are eligible for the registered nurse licensing examination.
of harm toward themselves or others without meeting the diagnostic Data were collected from students before they received any curricular
criteria of a disorder (Finnell et al., 2015; Mahmoud et al., 2017), and content related to alcohol use, education that can influence their atti-
toward persons with an alcohol use disorder and result in suboptimal tudes toward this patient population. These students, however, may
healthcare for these patients (Van Boekel et al., 2013). have had previous clinical or personal experiences with persons who
Recent publications have addressed the importance of shifting had alcohol use problems. In order to ensure anonymity of responses,
from pejorative language about this population to language that demographic data were not collected. A total of 651 students partici-
refers to these patients using person-first language (Broyles et al., pated in the study, of which only completed responses (n = 637) were
2014; Botticelli and Koh, 2016; Saitz, 2016). For example, rather included in the final analyses. This sample was randomly divided into
than using the term ‘drinkers’, the preferred language would be two datasets: one dataset was used for exploratory factor analysis
Alcohol and Alcoholism, 2020
(EFA) (n = 310), while the second dataset was used for confirmatory
factor analysis (CFA) (n = 327).
Measures
The AAPPQ (Gorman and Cartwright, 1991) consists of 30 items that
comprise two main scales: role security and therapeutic commitment.
Role security included items related to the adequacy of their knowl-
edge and skills in working with these clients (role adequacy, items 1–
7), how appropriate it is to work with these clients (role legitimacy,
items 8–11) and the extent to which they felt supported in their work
with clients (role support, items 12–14). Therapeutic commitment
included items related to motivation or willingness to work with the
population (motivation, items 15–19), self-esteem in the specific tasks
(task-specific self-esteem, items 20–25) and expectation of work sat-
isfaction (work satisfaction, items 26–30) (Gorman and Cartwright,
1991). Item responses were based on the level of agreement using
a 5-point scale ranging from 1 = strongly disagree to 5 = strongly
agree. The original AAPPQ showed good validity and reliability
(Cronbach’s alpha coefficients ranged between 0.7 and 0.9) at two
time points (pre-training and post-training) (Cartwright, 1980). In
this study, the original AAPPQ items (all items except items 1 and 15)
that contained pejorative terms were reworded using person-centered
language and addressed the continuum of alcohol use. For example,
the terms ‘drinkers’ and ‘drinking’ were reworded to ‘individuals who
drink alcohol’ and ‘alcohol use’, respectively. Afterward, the modified
PC-AAPPQ was reviewed by three members of the study team, who
are experts in the area of substance use, and consensus was reached.
Table 1 lists the items in the PC-AAPPQ showing the revised language
in italics and the original language in brackets.
Ethical considerations
The research was conducted in an established education setting
involving standard educational practices and was determined by both
IRBs to be exempt research.
Statistical analysis
Before examining the psychometric properties of the PC-AAPPQ,
negatively worded items were reverse coded in accord with the
original AAPPQ scoring method (Cartwright, 1980; Anderson and
Clement, 1987). This included 8 of 30 items: item 17, 18, 19, 21, 22,
23, 24 and 26. For the reliability analysis, the total sample was used
(N= 651); however, only surveys with complete data were included
in the factor analyses (n = 637). To obtain unbiased estimates for the
EFA and CFA, the study sample was then randomly divided into two
datasets.
Principal axis factoring and exploratory factor analysis
Using IBM® SPSS® Statistics Version 25 (IBM Corp., Armonk, NY)
and consistent with previous studies that examined AAPPQ factor
structure, a principal axis factoring (PAF) was performed with one of
the divided datasets (n = 310). The sample size of 310 fell within the
recommended 10 observations per variable ratio (Nunnally and Bern-
stein, 1994). The Kaiser-Meyer-Olkin (KMO) measure of sampling
adequacy (Kaiser, 1974) and Bartlett’s test of sphericity (Bartlett,
1950) were both examined to ensure that the correlation matrix was
factorable. The factor structure was examined using oblique (Pro-
max) rotation as it was expected that the subscales of the PC-AAPPQ
3
were correlated based on the therapeutic attitudes’ framework that
guided Cartwright’s original work (Cartwright, 1980).
First, the factors were extracted by examining factors with an
eigenvalue > 1. Based on the factor extracted and in order to replicate
the original AAPPQ factor structure, a six-factor structure was
forced. Second, items with a factor loading of >0.4 were retained
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in that factor. For items with cross loadings (i.e. items with loadings
of >0.4 on more than one factor), if the loading in one factor was
≥2 times its loading on the other factor(s), the decision was to place
the item on the factor with the highest loading. However, if the item’s
loading on one factor < 2 times its loading on the other factor(s),
the item was marked for further investigation. In addition, items
with loadings <0.4 were also marked for further analyses (Bartlett,
1950). Third, for further validation, a parallel analysis was performed
to decide the number of AAPPQ factors that should be retained
(Costello and Osborne, 2005). The parallel analysis uses the real
dataset, after setting the sample size (usually equal to the EFA sample
size), number of variables or items and value range for each item to
generate random dataset using SPSS or other programs (Hayton et al.,
2004). The created random dataset is used to extract eigenvalue using
similar techniques to that used with EFA. The eigenvalue generated
from the random set will be then compared to the one generated
from the EFA. To avoid risk bias that can result from using only
one random dataset, it is recommended to generate a reasonably
large number of random datasets (can range from 50 up to 1000
repetitions) and repeat the process mentioned earlier. The larger the
number of the repetitions performed, the more accurate the parallel
analysis findings are (Hayton et al., 2004). Therefore, in this study,
to perform the parallel analysis, a random dataset with the same
number of variables and a sample size of 310 was computed with
1000 repetitions. The data generated from this analysis (eigenvalue,
mean and 95th percentile) was then compared to the eigenvalue of
the actual EFA dataset. According to Hayton et al. (Hayton et al.,
2004) to retain any factor, the actual eigenvalue must be greater than
the mean eigenvalue computed from the parallel analysis.
Confirmatory factor analysis
The second divided dataset (n = 327) was used for CFA using
PROC CALIS method with SAS1 software 9.4 (SAS Institute, North
Carolina) in which items were forced to load into a single factor
within a specified factor structure. Model fit was examined across
the original six-factor structure, the forced five-factor structure and
the two model structures that resulted from the EFA. The models
were assessed using the root mean square approximation (RMSEA),
standardized root mean square residual (SRMSR), comparative fit
index (CFI), normed fit index (NFI) and non-normed fit index (NNFI)
to determine the fit between the observed data and the model. Hu
and Bentler (Hu and Bentler, 1999) recommendations were used to
determine a good model fit: RMSEA values of ≤0.60; SRMSR ≤0.80;
and CFI, NFI and NNFI values ≥0.90. Once the factor structure was
verified, the subscales generated in the analyses were labeled in accord
with those in the original AAPPQ.
Reliability
The internal consistencies of each of the subscales were measured
using the Cronbach’s alpha coefficient. Scale reliability is considered
acceptable if Cronbach’s alpha is between 0.70 and 0.80 (Nunnally
and Bernstein, 1994).
 4

Table 1. EFA factor loadings of the PC-AAPPQ (revised terminology in italic font) with initial factor Eigenvalues > 1 (n = 310)

Item Component

1 2 3 4 5 6 7 Original Communality

1. I feel I have a working knowledge of alcohol and alcohol-related problems 0.639a ADEQ 0.496
2. I feel I know enough about the causes of drinking problems to carry out my role when 0.842 ADEQ 0.774
working with individuals who drink alcohol [drinkers]
3. I feel I know enough about alcohol use disorder [alcohol dependence syndrome] to carry out 0.886 ADEQ 0.799
my role when working with individuals who drink alcohol [drinkers]
4. I feel I know enough about the psychological effects of alcohol to carry out my role when 0.811 ADEQ 0.696
working with individuals who drink alcohol [drinkers]
5. I feel I know enough about the factors, which put people at risk of developing alcohol-related 0.754 ADEQ 0.590
problems to carry out my role when working with individuals who drink alcohol [drinkers]
6. I feel I know how to counsel individuals who drink alcohol [drinkers] over the long term 0.727 ADEQ 0.602
7. I feel I can appropriately advise my patients about their alcohol use [drinking] and its effects 0.781 ADEQ 0.708
8. I feel I have a clear idea of my responsibilities in helping individuals who drink alcohol 0.686 LEGIT 0.544
[drinkers]
9. I feel I have a right to ask patients for any information that is relevant to their alcohol use 0.777 LEGIT 0.654
[about their drinking] when necessary
10. I feel that my patients believe I have the right to ask them questions about alcohol use 0.505 LEGIT 0.264
[drinking] when necessary
11. I feel I have the right to ask a patient for any information that is relevant to their alcohol use 0.613 LEGIT 0.404
[drinking] problems
12. If I felt the need when working with individuals who drink alcohol [drinkers] I could easily 0.700 SUPP 0.512
find someone with whom I could discuss any personal difficulties that I might encounter
13. If I felt the need when working with individuals who drink alcohol [drinkers], I could easily 0.904 SUPP 0.822
find someone who would help me clarify my professional responsibilities
14. If I felt the need I could easily find someone who would be able to help me formulate the best 0.856 SUPP 0.751
approach to an individual who drinks alcohol [drinker]
15. I am interested in the nature of alcohol-related problems and the responses that can be made to 0.599 MOT 0.422
them
16. I want to work with individuals who drink alcohol [drinkers] 0.656 MOT 0.501
17. I feel that the best I can personally offer individuals who drink alcohol [drinkers] is a referral 0.420 MOT 0.235
to somebody else
18. I feel that there is little I can do to help individuals who drink alcohol [drinkers] 0.604 0.406b MOT 0.418
19. Pessimism is the most realistic attitude to take toward individuals who drink alcohol [drinkers] 0.425 MOT 0.250
20. I feel I am able to work with individuals who drink alcohol [drinkers] as well as others 0.476 0.419 EST 0.336

Continued
Alcohol and Alcoholism, 2020

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Table 1. Continued

Item Component
Alcohol and Alcoholism, 2020

1 2 3 4 5 6 7 Original Communality

21. All in all I am inclined to feel I am a failure with individuals who drink alcohol 0.723 EST 0.573
[drinkers]
22. I wish I could have more respect for the way I work with individuals who drink alcohol 0.648 EST 0.439
[drinkers]
23. I feel I do not have much to be proud of when working with individuals who drink 0.687 EST 0.492
alcohol [drinkers]
24. At times I feel I am no good at all with individuals who drink alcohol [drinkers] 0.736 EST 0.571
25. On the whole, I am satisfied with the way I work with individuals who drink alcohol 0.421 0.409 0.430 EST 0.328
[drinkers]
26. I often feel uncomfortable when working with individuals who drink alcohol [drinkers] 0.573 SAT 0.375
27. In general, one can get satisfaction from working with individuals who drink alcohol 0.736 SAT 0.562
[drinkers]
28. In general, it is rewarding to work with individuals who drink alcohol [drinkers] 0.870 SAT 0.783
29. In general, I feel I can understand individuals who drink alcohol [drinkers] 0.451 0.433 0.653 SAT 0.584
30. In general, I like individuals who drink alcohol [drinkers] 0.508 SAT 0.308
% of Variance 22.42 11.50 6.38 4.74 3.54 2.31 1.77
Initial eigenvalues 7.15 3.87 2.26 1.87 1.56 1.21 1.07
Extracted sums of 6.73 3.45 1.92 1.42 1.06 0.69 0.53
squared loadings
Mean eigenvalue 1.63 1.54 1.47 1.42 1.37 1.32 1.28
from parallel
analysis

Note: ADEQ, role adequacy; LEGIT, role legitimacy; SUPP, role support; MOT, motivation; SAT, work satisfaction; EST, task-specific self-esteem.
a
Bold = highest factor loading over 0.4 for the item
b
Italics = loadings within ±2 of the highest loading.
5

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6 Alcohol and Alcoholism, 2020

RESULTS Table 2. Internal consistencies of the PC-AAPPQ seven-factor struc-

ture subscales (N = 651)
Exploratory factor analysis
Before conducting the EFA, both the Bartlett’s test of sphericity (χ 2 Factor No. of items n Cronbach’s α
(435) = 4233.449, P < 0.001) and the KMO measure of sampling
1 Role adequacya 8 649 0.917
adequacy (0.858) indicated the divided dataset (n = 310) was accept-
2 Role-related self-esteemb 9 647 0.609
able to perform an exploratory factor analysis.

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Seven factors had an eigenvalue >1, which explained 52.66%
of the PC-AAPPQ total variance. Communalities of individual items
ranged between 0.235 (item 17) and 0.822 (item 13). Table 1 pro-
vides more information regarding variance explained by each of the
seven factors, the eigenvalues for the seven factors and their loading
and communality values.
One of the four items of the original role legitimacy subscale
(item 8) loaded with the seven original items (items 1–7) of role
adequacy subscale forming Factor 1. Three items of the original
motivation subscale (items 17, 18 and 19) loaded with one item from
the original work satisfaction subscale (item 26) as well as four of the
five items (items 20–24) from the original task-specific self-esteem
subscale loaded together to form Factor 2. The original items of the
role support subscale loaded together forming Factor 3 (items 12–
14). Two items from the original work satisfaction subscale (items 27
and 28) loaded together to form Factor 4. The remaining three items
from the original role legitimacy subscale loaded together, forming
Factor 5 (items 9–11). Likewise, the remaining two items from the
original motivation subscale (items 15 and 16) loaded with item 25
from the original task-specific self-esteem subscale loaded to form
Factor 6. Factor 7 consisted of two remaining items of the original
work satisfaction subscale (items 29 and 30).
Four items had cross loadings (items 18, 20, 25 and 29). While the
cross loadings for each of these items were >0.4, none of the loadings
on the second factor were >2 times the loading on the other factor(s).
These four items were marked for further analyses.
The parallel analysis, which is considered an accurate analysis for
determining the number of factors that should be retained (Nunnally
and Bernstein, 1994; Hayton et al., 2004; Costello and Osborne,
2005), indicated that only five eigenvalues had higher values than
the mean eigenvalues generated from the parallel analysis. For that
reason, an EFA with a forced five-factor solution was conducted. A
forced six-factor solution was also conducted to replicate the AAPPQ
original factor structure. In both EFA forced structures, the same
dataset (n = 310) was used. In addition, two EFA were performed:
(Cartwright, 1980) EFA with forced six-factor solution and (Gorman
and Cartwright, 1991) EFA with forced five-factor solution.
Factor labels
To the extent possible, the seven-factor structure was labeled using
the terms from the original six-factor structure. Consistent with
the original labeling, Factors 1, 3, 4, 5 and 6 were labeled role
adequacy, role support, work satisfaction, role legitimacy and moti-
vation, respectively. In the current study the task-specific self-esteem
was relabeled as role-related self-esteem subscale because in addition
to retaining items 20–24 from the original task-specific self-esteem
subscale, it also consisted of several items from the original motiva-
tion scale (items 17–19) and one item from the original satisfaction
scale (item 26), which had the highest loadings on the esteem subscale,
increasing it from six items to nine. Factor 7, which consisted of two
items from the original work satisfaction subscale (items 29 and 30),
was labeled as general perceptions related to alcohol use.
3 Role support 3 649 0.850
4 Work satisfaction-1c 2 650 0.753
5 Role legitimacyd 3 648 0.706
6 Motivatione 3 611 0.583
7 General perceptionsf 2 650 0.615
a
With item 8 (LEGIT)
b
without item 25 and with items 17–19 (MOT), 26 (SAT)
c
without items 26, 29, 30;
d
without item 8
e
without items 17–19 and with item 25 (EST)
f
includes items 29 and 30.
Note: ADEQ, role adequacy; LEGIT, role legitimacy; SUPP, role support;
MOT, motivation; SAT, work satisfaction; EST, task-specific self-esteem.
Subscale reliabilities
The total sample was used to calculate subscale internal consistency.
Reliabilities were performed using all 30 items. With the exception
of the six-factor structure (Cronbach α = 0.583), the Cronbach α
subscales were satisfactory and ranged between 0.609 and 0.917.
Based on the Nunnally and Bernstein (Nunnally and Bernstein,
1994) recommended range, the study findings revealed that Factor 2
(role-related self-esteem subscale, Cronbach α = 0.609) and Factor
6 (motivation subscale, Cronbach α = 0.583) had relatively low
reliabilities for the seven-factor structure. To increase reliabilities,
internal consistencies of these subscales were reassessed after remov-
ing the three items (items 18, 20 and 25) marked earlier for further
evaluation.
The results showed that the reliability of the role-related self-
esteem decreased from α = 0.609 to 0.504 when item 18 was
removed. Similarly, the role-related self-esteem subscale’s reliability
decreased from α = 0.609 to 0.544 when item 20 was removed.
When both items 18 and 20 were removed, the role-related self-
esteem subscale’s reliability also decreased from α = 0.609 to 0.403.
The decision was made to retain both items 18 and 20. Likewise, item
25 was reexamined. The findings indicated that the reliability of the
work satisfaction subscale increased from α = 0.583 to 0.705 when
item 25 was removed. Thus, the decision was made to examine the
seven-factor structure without item 25 using CFA. See Table 2 for the
internal consistencies of the seven-factor structure.
Internal consistencies for the forced six-factor structure subscales
were also reassessed. Based on the findings of the forced six-factor
structure subscales, the decision was made to examine two six-factor
structures using CFA: (Cartwright, 1980) six-factor structure without
item 25 and (Gorman and Cartwright, 1991) six-factor structure
without items 25, 29 and 30.
Finally, the internal consistencies of the forced five-factor struc-
ture were reexamined. Based on the findings of the analysis, the
decision was made to conduct a CFA of the five-factor structure
without item 10.
Confirmatory factor analysis
The second dataset (n = 327) was used to conduct the CFA. Based
on the EFA and reliability findings, eight different factor structures
were compared using the CFA:
Alcohol and Alcoholism, 2020 7

Table 3. Confirmatory factor analyses of the PC-AAPPQ (N = 327)

Structure Chi-Square RMSEA (90% CI) SRMSR CFI NFI NNFI

Model 1: Seven-factor structure with χ 2 = 858.59, df = 384, p < 0.001 0.065 (0.059, 0.071) 0.071 0.871 0.793 0.855
30 items
Model 2: Seven-factor structure χ 2 = 910.20, df = 356, p < 0.001 0.073 (0.067, 0.078) 0.072 0.848 0.775 0.826

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without item 25
Model 3: Six-factor structure with χ 2 = 1042.58, df = 390, p < 0.001 0.076 (0.070, 0.081) 0.082 0.823 0.748 0.803
30 items
Model 4: Six-factor structure χ 2 = 952.26, df = 362, p < 0.001 0.075 (0.068, 0.080) 0.076 0.838 0.764 0.818
without item 25
Model 5: Six-factor structure χ 2 = 847.56, df = 309, p < 0.001 0.077 (0.071, 0.083) 0.073 0.844 0.777 0.823
without items (25, 29 and 30)
Model 6: Six-factor structure with χ 2 = 1041.88, df = 390, p < 0.001 0.075 (0.070, 0.081) 0.091 0.823 0.748 0.803
30 items similar (original factor
structure)
Model 7: Five- factor structure with χ 2 = 1030.02, df = 395, p < 0.001 0.074 (0.068, 0.079) 0.086 0.828 0.751 0.811
30 items
Model 8: Five-factor structure χ 2 = 977.47, df = 367, p < 0.001 0.075 (0.069, 0.081) 0.087 0.830 0.755 0.812
without item 10

Note. RMSEA = root mean square approximation; CI = confidence interval; SRMSR = standardized root mean square residual; CFI = comparative fit index;
NFI = normed fit index; NNFI= non-normed fit index.

• The seven-factor structure with all 30 items. In this factor structure,
item 8 was placed in Factor 1; items 17, 18, 19 and 26 were placed
in Factor 2; item 25 was placed in Factor 6; and items 29 and 30
created Factor 7.
• The seven-factor structure without item 25.
• The six-factor structure with all 30 items. Like the seven-factor
structure, item 8 was placed in Factor 1; items 17, 18, 19 and 26
were placed in Factor 2; and item 25 was placed in Factor 6.
• The six-factor structure without item 25.
• The six-factor structure without items 25, 29 and 30.
• The original six-factor structure.
• The five-factor structure with all 30 items. In this factor structure,
item 8 was placed in Factor 1; items 17, 18, 19 and 26 were placed
in Factor 2; and items 27, 28, 29 and 30 were placed in Factor 3.
• The five-factor structure without item 10.
Table 3 presents the results of the CFA. The seven-factor structure
had the lowest RMSEA and SRMSR values and the highest CFI, NFI
and NNFI values when all 30 items were included in the model.
Compared to all the models generated from the EFA, neither the
original six-factor structure nor the five-factor structure was superior
to any of the other models. Thus, when all the eight models were
compared, the seven-factor solution with all 30 items had the best fit.
DISCUSSION
The purpose of this study was to examine the psychometric properties
of the AAPPQ with revised person-centered language. This revised
language is now more reflective of the language used within the
substance use prevention and treatment field, which has undergone
an intentional shift in language over the past decade to reduce the
stigma associated with at-risk alcohol use, that is, any amount of
alcohol that increases harm to the individual or others.
The EFA and CFA results indicate that a seven-factor structure
with all 30 items is the best fit for the PC-AAPPQ. An AAPPQ
seven-factor structure was also observed in two previous studies: one
conducted on general practitioners (GPs) (Anderson and Clement,
1987) and the other on undergraduate nursing students (Terhorst
et al., 2013). Although Anderson and Clement extracted a seven-
factor structure using PAF with oblique rotation, they did not explore
this structure further and instead forced a six-factor structure. Thus,
the authors did not confirm whether a seven-factor structure was
appropriate for the GP population. On the other hand, Terhorst
et al. study (Terhorst et al., 2013) on undergraduate nursing students
proposed a seven-factor structure without 3 items (19, 20 and 25)
reporting Cronbach’s alpha coefficients ranging from 0.71 to 0.90.
The PC-AAPPQ in the current study has more items than those
found in Terhorst et al. study (Terhorst et al., 2013); however,
several subscales are similar. For example, both studies reported the
same structure for the following subscales: role adequacy (items 1–
8), role legitimacy (items 9–12), role support (items 12–14) and
work satisfaction (items 27 and 28) subscales. However, the seventh
factor in the PC-AAPPQ resulted from the original work satisfaction
subscale items splitting into two distinct subscales with one reflecting
satisfaction associated with working with individuals who use alco-
hol (items 27 and 28) and the other reflecting a more general attitude
toward alcohol use (items 29 and 30). The seventh factor in Terhorst
et al. study (Terhorst et al., 2013) resulted from the split of the original
motivation subscale into two distinct subscales with one reflecting
motivation to provide alcohol-related care (items 15, 16, 29 and 30)
and the other reflecting a lack of confidence in performing such care
(lack of confidence subscale with items 17–19). Other differences
between the two studies are found in the motivation and role-related
self-esteem subscales. In Terhorst et al. study (Terhorst et al., 2013),
the motivation subscale consisted of two items from the original
motivation subscale (items 15 and 16) and two items of the original
satisfaction subscale (items 29 and 30). Meanwhile, the PC-AAPPQ
motivation subscale consisted of the same two items from the original
motivation subscale and one item from the esteem subscale. In the
current study, the task-specific self-esteem was relabeled as role-
related self-esteem subscale because in addition to retaining items
20–24 from the original task-specific self-esteem subscale, it also
consisted of several items from the original motivation scale (items
17–19) and one item from the original satisfaction scale (item 26),
which had the highest loadings on the esteem subscale, increasing it
from six items to nine. Although both Terhorst et al. study (Terhorst
8 Alcohol and Alcoholism, 2020
et al., 2013) and the current study were conducted on undergraduate
nursing students, the slight differences observed in the seven-factor
structure among the two studies may be attributed to the change in
terminology. However, it is important to consider other factors that
may have contributed to the slight change in factor structure such
as age, race and clinical experience. Further studies that replicate the
current study should be conducted to confirm this factor structure.
Given the need to evaluate students’ perceptions and attitudes
toward persons who use alcohol, utilizing an instrument that included
pejorative terms was in stark contrast to what was being taught.
Utilizing the existing AAPPQ would undermine the efforts being
taken within the curricula to mitigate the stigma experienced by this
vulnerable population. In completing the PC-AAPPQ, respondents
are not exposed to pejorative language or language that may nega-
tively impact the way the respondent may perceive alcohol use and the
people affected by it. Thus, this contemporary version of the AAPPQ
reflects the values of respecting the worth and dignity of all persons
and avoids perpetuating negative stereotype biases through the use
of language that is not person-centered.
LIMITATIONS
All participants were prelicensure students and were beginning
curricula in which integrated substance use-related didactic and
clinical experiences throughout their time in the program, while
the original AAPPQ was administered to general practitioners. Some
differences encountered could be related to differing perspectives of
nurses versus physicians and/or the impact of clinical experience
in shaping attitudes toward individuals who use alcohol. Thus,
since the study focused on nurses, it may not be as representative
of all healthcare professionals. Although the students may have
had previous clinical and/or personal experience with patients,
family members or significant others with alcohol use problems,
their responses may differ from nurses with experience or those
working in the field of addictions. In addition, to ensure anonymity
of responses, demographic data were not collected, thus limiting our
ability to generalize the study findings to other undergraduate nursing
populations. Future research should administer the PC-AAPPQ to a
more diverse group of nursing students, to other health professional
students and to health professionals who are engaged in clinical
practice to determine if the factor structure identified in this study is
consistent across nursing and health profession program and across
the spectrum of practice experience.
CONCLUSIONS AND FUTURE IMPLICATIONS
Though there were some shifts in items between subscales and an
increase in the overall number of subscales, taken as a whole, the PC-
AAPPQ maintains the intent of the original AAPPQ and represents a
positive effort to modernize the language in this nearly four-decade-
old instrument. Future researchers interested in measuring health pro-
fessionals’ therapeutic attitudes toward individuals who use alcohol
should consider utilizing this contemporary patient-centered measure
that considers the alcohol use continuum.
FUNDING
This work was supported by funding from the Substance Abuse and
Mental Health Services Administration (5H79 TI025964-02 [DSF];
5H79TI081660-02 [AMM]).
COMPETING INTERESTS
All the authors declare that there is no conflict of interest.
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