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International Journal of Nursing Practice 2015; 21: 913–922
RESEARCH PAPER
Psychometric testing of the Chinese Mandarin version of the Mental Health Inventory among Chinese patients with coronary heart disease in Mainland China Meili Liu BSN RN Senior Nurse, Cardiovascular Department, First Affiliated Hospital of Medical College of Xi’an Jiaotong University, Xi’an, Shaanxi, China
Aloysius Chow BPsych (Hons) Research Assistant, Alice Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Ying Lau PhD RN Assistant Professor, Alice Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Hong-Gu He, PhD RN Assistant Professor, Alice Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Wenru Wang PhD RN Assistant Professor, Alice Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Accepted for publication August 2013 Liu M, Chow A, Lau Y, He H-G, Wang W. International Journal of Nursing Practice 2015; 21: 913–922 Psychometric testing of the Chinese Mandarin version of the Mental Health Inventory among Chinese patients with coronary heart disease in Mainland China This study aimed to develop a Chinese Mandarin version of the Mental Health Inventory (CM:MHI). The English version MHI was translated into Chinese (simple Chinese character) using the forward-backward translation method while establishing the semantic equivalence and content validity. A convenience sample of 204 coronary heart disease (CHD) patients was recruited to evaluate the internal consistency, concurrent validity and construct validity of the CM:MHI. Forty patients completed the CM:MHI to evaluate the test–retest reliability after 2 weeks. The CM:MHI demonstrated good semantic equivalent rate (92%) and satisfactory content validity index (0.91). The internal consistency was acceptable for total and all subscales with Cronbach’s alpha greater than 0.70, with the exception of the subscale of Emotional Ties (Cronbach’s alpha = 0.64). The test–retest reliability was also satisfactory with intraclass correlation coefficients higher than 0.75. The concurrent validity was acceptable with significantly strong correlations
Correspondence: Wenru Wang, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, Level 2, Clinical Research Centre, Block MD 11,10 Medical Drive, Singapore 117597. Email: [email protected] doi:10.1111/ijn.12301
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between the CM:MHI and the Chinese Mandarin versions of Short Form 36 Health survey and Hospital Anxiety and Depression Scale. Confirmatory factor analysis further supported the five-factor structure of the CM:MHI. The CM:MHI demonstrated to be a valid and reliable measure for assessing psychological distress and well-being in Chinese-speaking CHD patients. Key words: Chinese, cross-cultural validation, heart disease, psychological distress, psychological well-being.
INTRODUCTION
The growing rates of industrialization and urbanization in Mainland China have inadvertently introduced a Westernized lifestyle into the lives of the Chinese people. Unfortunately, this Western influence on the diets and lifestyles of the Chinese people, contributed to an increased incidence of health problems like diabetes, hypertension and obesity.1 These health problems are also risk factors for coronary heart disease (CHD), which is currently one of the leading causes of physical disability and decreased quality of life worldwide.2 Together with an ageing population and increasing internal migration from rural to Westernized urban cities, the prevalence of CHD in Mainland China is expected to increase in the near future. This concern is supported by a computer simulation model, the CHD Policy Model-China, which looked at how urbanization would affect Mainland China.3 From this model, it was reported that the incidence of CHD in Mainland China is expected to increase by two times between 2010 and 2030.3 Several studies have been conducted in mainland China to explore the experiences of Chinese CHD patients, and the results consistently indicated that the patients were going through a ‘life-threatening illness’, adjusting to a different lifestyle because of CHD and ‘help-seeking behaviour’.2,4–6 Affected individuals are also faced with the threat of family life alteration, strained marital relationships, economic burden and fewer job opportunities.4 All these lead to frustration, despair, loss of hope and impaired quality of life.4–6 These also highlight that Chinese CHD patients experience a significant amount of psychological stress. It has been documented that stress adversely affects the cardiovascular system because stress can cause an imbalance to our sympathetic– parasympathetic system and modify our hypothalamic– pituitary–adrenal axis which are responsible for regulating many of our bodily functions, such as the cardiovascular system.7–10 A large sample prospective study reported that participants who actively exhibited positive affects had a lower risk of developing CHD over a 10 year period.11 © 2014 Wiley Publishing Asia Pty Ltd
Davidson and her colleagues suggested that the positive affect had an indirect effect on the participants, such as increased quality of sleep and decreased number of people who smoked.11 Therefore, health-care professionals ought to be encouraged to help CHD patients manage stress better to reduce the effect of this risk factor, as CHD patients tend to report experiencing a significant amount of psychological distress.12 To allocate resources efficiently, it is important for health-care professionals to have an objective and accurate instrument to assess for psychological distress in CHD patients. The Mental Health Inventory (MHI) is such an instrument as it can assess both psychological distress and well-being .13 While developing the MHI, Veit and Ware proposed that assessing for well-being would provide a more accurate measurement of the mental state of an individual, as compared with merely measuring psychological distress alone.13 The MHI has been widely used with respectable psychometrical standards reported for different types of chronic diseases like cancer,14–16 dermatological diseases,17 for use with adolescents,18 and there are several abridged versions of the MHI as well.19 To be more accessible, the MHI has also been translated into different languages like Farsi20 and Chinese.21 A simplified Chinese version of the MHI will be beneficial for use in Mainland China, considering the vast number of CHD patients currently and in the near future.2,3 However, the current Chinese version is presented in traditional Chinese, and simplified Chinese is used in Mainland China. There are cognitive differences (e.g. visual recognition and mental processing) when reading the written characters of traditional and of simplified Chinese.22 In addition, the current traditional Chinese version of the MHI was validated with a sample from Taiwan,21 where the culture, economic and social background is different from Mainland China. Therefore, a simplified Chinese version will be better received by both health-care professionals and CHD patients in Mainland China, and provide a more accurate assessment of psychological distress and well-being.
Psychometrics of Mental Health Inventory
METHODS This study evaluating the psychometric properties of the Chinese Mandarin version of the MHI (CM:MHI) was conducted in two phases. The aims of the first phase were to translate the original English version of the MHI into Chinese Mandarin (simple Chinese characters), and thereafter examine the semantic equivalent and content validity of the CM:MHI. The second phase aimed at examining the internal consistency, test–retest reliability, concurrent validity and factor structure of this translated assessment tool.
PHASE ONE: TRANSLATION AND DEVELOPMENT OF THE CM:MHI The forward-backward translation method was used in this study.23 A bilingual research assistant translated the English MHI into simplified Chinese. Thereafter, an independent translator conducted a back-translation into English. The focus of the translation was on the conceptual equivalence of the items.23 Conceptual equivalence refers to whether the concepts of the phenomena being studied possessed the same conceptual meanings in both cultures.24 After the translation discrepancies in the CM:MHI had been clarified, the resulting version was examined for semantic equivalence. Ten bilingual health-care professionals were invited to evaluate the equivalence of translation between each item of the original English and translated Chinese version of MHI using a 4-point rating form (1 = not equivalent, 2 = somewhat equivalent, 3 = quite equivalent and 4 = most equivalent). Next, an expert panel consisting of two physicians, one psychologist, four nurse specialists and three nurse educators were recruited to provide their feedback on the cultural relevance and content validity of the CM:MHI for use in Mainland China. This expert panel was also asked to evaluate the CM:MHI in terms of cultural relevance and content validity as a measure for psychological distress and well-being for the Chinese population with CHD using a 4-point rating scale (1 = not relevant, 2 = somewhat relevant, 3 = relevant and 4 = very relevant).
PHASE TWO: PSYCHOMETRIC PROPERTIES TESTING In the second phase of the study, a convenience sample of 204 patients with CHD was recruited from two general public hospitals in Xi’an city, People’s Republic of China. The inclusion criteria included: (i) a diagnosis of CHD; (ii)
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being able to read simple Chinese characters; (iii) have no evidence of current or past psychiatric illness; and (iv) have no severe mobility problems. In accordance with the recommendation of 5–10 subjects per questionnaire item for the assurance of the accuracy in estimating the model parameters,25 a minimum sample size of 190 was needed for the 38-item CM:MHI. A total of 204 subjects were recruited to participate in this study eventually. Permission to conduct the study was sought from the ethical committees of two hospitals. With consent obtained from the participants, a research assistant administered the instrument to them at both hospitals. Each interview required approximately 20 min. To investigate the test–retest reliability, 40 subjects were randomly selected from the primary sample and asked to complete the CM:MHI again in 2 weeks.
Instruments The MHI
The MHI has been widely used to measure the psychological distress and well-being in both general populations and patients with chronic disease.13–16 It consists of 38 items and is divided into two higher-order subscales: Psychological Distress and Psychological Well-being. Psychological Distress is divided into subscales labelled Anxiety (10 items), Depression (5 items) and Loss of Behavioral/Emotional Control (9 items). Psychological Well-being is further divided into second-order subscales of Emotional Ties (3 items) and General Positive Affect (11 items). All of the items are scored on a six-point scale (i.e. range 1–6), except two (items 9 and 28) which are scored on a fivepoint scale (i.e. range 1–5). For the Psychological Distress subscale, including Anxiety, Depression and Loss of Behavioral/Emotional Control, higher score implies greater psychological distress. Whereas in the Psychological Well-being subscale, including General Positive Affect and Emotional Ties, higher score indicates better psychological well-being. The Cronbach’s alphas for the Psychological Distress and Psychological Well-being were reported as 0.94 and 0.92, respectively, and those of the five subscales ranged between 0.81 and 0.92.13
The Chinese Mandarin version of the Short Form-36 health survey (CM:SF-36)
The SF-36, a robust and widely used scale for the measurement of health status, comprises of 36 items in eight subscales (i.e. physical functioning, role functional © 2014 Wiley Publishing Asia Pty Ltd
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physical, role functioning emotional, mental health, social functioning, bodily pain, general health perceptions and vitality).26 Each subscale score ranges from 0 to 100, with a higher score indicating better quality of life.26 The subscale scores can be divided into physical and mental component summary scales. The SF-36 is psychometrically sound in numerous population samples.27 The CM:SF-36 has demonstrated good validity and reliability with acceptable internal consistency for all subscales (Cronbach’s alpha 0.64–0.93) and the test–retest reliability being adequate with the intraclass correlation coefficient (ICC) of 0.75 for all subscales.28
The Chinese Mandarin version of Hospital Anxiety and Depression Scale (CM:HADS)
The HADS is a 14-item questionnaire and can be divided evenly into the anxiety and depression subscales.29 The items are rated on a four-point scale with a range from 0 to 3 with fixed response statements, whereby a higher score represents a higher level of psychological distress. The CM:HADS was reported to have good reliability and validity.30 Cronbach’s alphas for the total scale, anxiety and depression subscales were found to be 0.85, 0.79 and 0.79, respectively.30
The demographic and clinical data sheet
A demographic and clinical data sheet was developed to collate data regarding the participant’s demographic variables and clinical information.
Data analysis IBM SPSS Statistics version 20.0 (Armonk, NY, USA) was used for analysing the psychometric properties, such as internal consistency, test–retest reliability, concurrent validity and factor structure. The internal consistency of scale was tested using the Cronbach’s alpha and itemto-total correlations. The internal consistency of each subscale was accepted for group comparison if the Cronbach’s alpha coefficient was greater than 0.7. The test–retest reliability was evaluated using ICC, and r > 0.75 suggested adequate stability.31 A Pearson correlation test was used to evaluate the concurrent validity of CM:MHI with the CM:SF-36 and CM:HADS. A P-value of 0.05 was accepted as a significant level of correlation. A confirmatory factor analysis (CFA) was performed using Amos 18.0 (SPSS Inc., Chicago, IL, USA) to examine the factor structure of CM:MHI. The overall data-model fitness of CM:MHI was examined by the © 2014 Wiley Publishing Asia Pty Ltd
commonly used ‘goodness of fit’ indices. These included the chi-square/degree of freedom ration (χ2/df), the normal and non-normal fit indices (NFI and NNFI), comparative fit index (CFI), root mean square error of approximation (RMSEA), and incremental fit index (IFI). Model fit is deemed acceptable with χ2/df ≤ 3, NNFI > 0.9, CFI > 0.9, RMSEA < 0.08 and IFI > 0.9.32
RESULTS Semantic equivalence and content validity With regard to the semantic equivalence, all the items were rated by at least 80% of the raters as having ‘quite equivalent’ or ‘most equivalent’, with the average equivalent rate being 92%, indicating that the Chinese Mandarin version was a correct refection of the English version. For the content validity, the expert panel rated that all 38 items of the CM:MHI are culturally relevant for Chinese patients with CHD. The content validity index, which is the percentage calculated based on the total items rated by the experts as either 3 or 4,33 was 0.91, indicating a good content validity.
Sample A total of 246 CHD patients were approached, and 204 (82.9%) of them were recruited from the cardiac outpatient clinic of two general public hospitals in Xi’an City of China for testing the psychometric properties of the CM:MHI. There were 139 (68.1%) men and 65 (31.9%) women. The mean age of the subjects was 63.1 years (SD = 11.8, range 29–88). Half of the subjects had high cholesterol and nearly one fourth had the comorbidity of heart failure (Table 1).
Internal consistency and reliability The internal consistency of the two higher-order subscales and the five second-order subscales as well as the total scale was satisfactory, with Cronbach’s alpha > 0.70, with the exception of the subscale of Emotional Ties (Cronbach’s alpha = 0.64). The correlations between items and their respective subscale were significantly high, with Pearson correlation coefficients ranging between 0.43 and 0.88. All of the ICCs of the total and subscale scores were higher than 0.75, indicating an adequate test– retest reliability. The Cronbach’s alphas, item-total correlations and ICCs of each subscale are shown in Table 2.
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Table 1 Sociodemographic and clinical characteristics of the sample (n = 204) Variable Sex Male Female Marital status Married Not married† Educational level (years) Primary or less (< 6) Secondary (7–13) Tertiary (> 13) Occupation Full-time job Part-time and retired Smoking status Current smoker Ex-smoker Coronary family history Yes No High cholesterol Yes No Hypertension Yes No Comorbidity with heart failure Yes No Comorbidity with diabetes Yes No
Frequency
Percentage
139 65
68.1 31.9
185 19
90.7 9.3
47 109 48
23.1 53.4 23.5
135 69
66.2 33.8
30 96
14.7 47.1
62 142
30.4 69.6
102 102
50.0 50.0
135 69
66.2 33.8
45 159
22.1 77.9
47 157
23.0 77.0
†
Not married includes single, divorced or widowed.
Concurrent validity There were significant correlations between the CM:MHI and the relevant dimensions of the CM:SF-36 and the CM:HADS (Table 3). The results of Pearson productmoment correlation coefficients indicated that the concurrent validity for the CM:MHI was confirmed with significant and moderate/high correlations between the subscales of the CM:MHI and the CM:HADS anxiety (r = 0.33–0.89, P < 0.01) and depression (r = − 0.32 to 0.76, P < 0.01) scales. There were significant and moderate/high correlations between the CM:SF-36
mental component subscale and all CM:MHI subscales (r = 0.22 to − 0.64, P < 0.01). The CM:SF-36 physical component subscale had also significant correlations with the CM:MHI subscales of Anxiety (r = − 0.24, P < 0.01), Depression (r = − 0.17, P < 0.05) and General Positive Affect (r = 0.25, P < 0.01).
Construct validity: Known-groups comparison The results of know-groups comparison lent further evidence to support the construct validity of CM:MHI. Comparison of the mean scores of the subscales of the CM:MHI with gender, age and comorbidities with heart failure and diabetes is shown in Table 4. The results indicated that women had significantly lower scores on Loss of Behavioral/ Emotional control (P < 0.05), whereas older patients scored significantly lower on the Emotional Ties (P < 0.05). Patients with comorbidity with heart failure had significantly higher score of psychological distress (P < 0.05) and lower score of psychological well-being (P < 0.05). However, no any significant differences were found between the patients with or without comorbidity with diabetes (P > 0.05).
Factor structure The goodness of fit indices demonstrated a better data model fit with the χ2/df being 2.74, the NFI being 0.86, NNFI being 0.90, CFI being 0.91 and RMSEA being 0.061. For the parameter estimation, all the items loaded significantly onto their respective factor, with factor loading ranging from 0.41 to 0.90 (Fig. 1). The findings therefore affirmed the five-factor structure of the CM:MHI and added evidence of its factor structure. In addition, the correlations between the factors of Anxiety, Depression and Loss of Behavioral/Emotional Control, as well as the correlation between the factors of General Positive Affect and Emotional Ties were very strong (r > 0.86). This indicates that the respective subscales were measuring the similar sub-construct—psychological distress and well-being.
DISCUSSION Although the MHI has been widely used to assess the mental health in both general population and individuals with chronic disease,13–16 including patients with CHD,12 this is the first study to report the psychometric properties of the Chinese Mandarin version of the MHI (simple © 2014 Wiley Publishing Asia Pty Ltd
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Table 2 Internal consistency (item-to-total correlations and Cronbach’s alpha coefficients) and test–retest reliability of the CM:MHI Domain
Psychological distress Anxiety Item 3. Nervous and jumpy Item 11. Very nervous person Item 13. Felt tense or high-strung Item 15. Hands shake when doing things Item 22. Relax without difficulty Item 25. Bothered by nervousness Item 29. Restless, fidgety, impatient Item 32. Rattled, upset, or flustered Item 33. Anxious, worried Item 35. Difficulty trying to calm down Depression Item 9. Felt depressed Item 19. Downhearted and blue Item 30. Moody, brooded about things Item 36. Low or very low spirits Item 38. Strain, stress, pressure Loss of Behavioral/Emotional Control Item 8. Concern about losing control of mind Item 14. Control of behavior, thoughts, feelings Item 16. Nothing to look forward to Item 18. Felt emotionally stable Item 20. Felt like crying Item 21. Better off if dead Item 24. Nothing turns out as wanted Item 27. Down in the dumps Item 28. Think about taking own life Psychological Well-being General Positive Affect Item 1. Happy, satisfied, or pleased Item 4. Future hopeful, promising Item 5. Daily life interesting Item 6. Relaxed and free of tension Item 7. Generally enjoyed things Item 12. Expect an interesting day Item 17. Felt calm and peaceful Item 26. Living a wonderful adventure Item 31. Felt cheerful, lighthearted Item 34. Happy person Item 37. Wake up fresh, rested Emotional Ties Item 2. Time felt lonely Item 10. Felt loved and wanted. Item 23. Love relations full, complete Overall score
Item-to-total correlation (n = 204)
Intraclass coefficient (n = 40)
0.90 0.73
0.86 0.84
0.81
0.79
0.77
0.78
0.83 0.76
0.89 0.81
0.64
0.82
0.81
0.89
0.57 0.71 0.77 0.47 0.50 0.80 0.69 0.60 0.76 0.60 0.77 0.86 0.74 0.88 0.40 0.53 0.78 0.53 0.53 0.55 0.53 0.46 0.59 0.48
0.60 0.73 0.81 0.59 0.82 0.71 0.67 0.61 0.76 0.79 0.65 0.43 0.73 0.58
CM:MHI, Chinese Mandarin version of the Mental Health Inventory.
© 2014 Wiley Publishing Asia Pty Ltd
Cronbach’s alpha (n = 204)
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Table 3 Pearson correlations of the association between the CM:MHI and the CM:SF-36 domains and the CM:HADS anxiety and depression subscales (n = 204) Domain
CM:SF-36 SF-36 PCS SF-36 MCS CM:HADS Anxiety subscale Depression subscale
CM:MHI Anxiety
Depression
Loss of Behavioral/ Emotional Control
− 0.24** − 0.54**
− 0.17* − 0.64*
− 0.13 − 0.53**
0.25** 0.55**
0.05 0.22**
0.33** 0.54**
− 0.45** − 0.32**
− 0.47** − 0.43**
0.89** 0.68**
0.61** 0.76**
General Positive Affect
Emotional Ties
* Significant at 0.05, ** Significant at 0.01. CM:HADS, Chinese Mandarin version of Hospital Anxiety and Depression Scale ; CM:MHI, Chinese Mandarin version of the Mental Health Inventory; CM:SF-36, Chinese Mandarin version of the Short Form-36 health survey; MCS, mental component subscale; PCS, physical component subscale. Table 4 Comparison of scale means of various dimensions of CM:MHI by gender, age and comorbidities with heart failure and diabetes Variable
Gender Male (n = 139) Female (n = 65) P-value Age < 65 years (n = 112) ≥ 65 years (n = 92) P-value Comorbidity with heart failure No (n = 159) Yes (n = 45) P-value Comorbidity with diabetes No (n = 157) Yes (n = 47) P-value
Anxiety
Depression Loss of Behavioral/ General Emotional Emotional control positive affect ties
Psychological Psychological distress well-being
25.2 ± 6.8 21.4 ± 3.6 34.4 ± 3.1 26.9 ± 6.9 20.8 ± 3.5 33.4 ± 3.5 0.107 0.319 0.033*
30.7 ± 8.4 32.2 ± 7.8 0.229
12.4 ± 2.7 81.0 ± 4.5 12.0 ± 2.8 81.1 ± 4.5 0.308 0.872
43.2 ± 6.6 44.2 ± 6.2 0.270
25.7 ± 6.5 21.1 ± 3.4 34.2 ± 3.1 25.9 ± 7.4 21.4 ± 3.7 33.8 ± 3.4 0.820 0.550 0.416
30.9 ± 8.4 31.7 ± 8.0 0.489
12.7 ± 2.7 81.0 ± 4.1 11.8 ± 2.8 81.1 ± 5.0 0.032* 0.845
43.5 ± 6.6 43.5 ± 6.3 0.959
25.3 ± 6.8 21.5 ± 3.5 34.1 ± 3.4 28.3 ± 7.0 23.4 ± 3.9 35.9 ± 2.7 0.001** 0.049* 0.214
33.5 ± 8.0 30.6 ± 8.6 0.038*
12.4 ± 2.7 80.9 ± 4.6 11.9 ± 2.9 84.5 ± 4.0 0.280 0.014*
45.2 ± 6.3 42.0 ± 6.3 0.045*
25.5 ± 6.6 21.3 ± 3.5 34.1 ± 3.4 26.7 ± 7.8 22.0 ± 3.6 35.8 ± 2.7 0.315 0.630 0.541
31.1 ± 8.3 31.5 ± 7.8 0.781
12.4 ± 2.8 80.1 ± 4.1 11.9 ± 2.6 81.5 ± 5.3 0.358 0.458
43.8 ± 6.5 43.2 ± 6.5 0.967
** Significance at the level of P < 0.01. * Significance at the level of P < 0.05. CM:MHI, Chinese Mandarin version of the Mental Health Inventory.
Chinese characters) among Chinese population with CHD in Mainland China. The results of our study demonstrated the good psychometric properties of the CM:MHI in terms of semantic equivalence, content validity, internal consistency, test–retest reliability and construct validity.
The forward and backward translation process recommended by Brislin was rigorously carried out,23 and this ensured semantic, cultural equivalence and content validity. Evidence for the internal consistency of CM:MHI was demonstrated by the high values of Cronbach’s alpha of © 2014 Wiley Publishing Asia Pty Ltd
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Figure 1. Confirmatory factor analysis of the CM:MHI.
the overall scale, two first-order subscales and the secondorder subscales with the exception of the subscale of Emotional Ties (r = 0.64). The relative lower Cronbach’s alpha for the subscale of Emotional Ties indicates that the internal consistency of this subscale might not be acceptable. However, this would not greatly impact the utilization of the scale as the internal consistency for the overall scale is satisfactory.33 The results of the item analysis further indicated the homogeneity of the items to its own scale, indicating the internal consistency of their respective items in measuring the sub-constructs.31 As for stability, the results from 40 participants demonstrated satisfactory test–retest reliability for the overall scale and all sub-scales, indicating the stability of the instrument in measuring the constructs. The concurrent validity of the CM:MHI was established by its significant and strong correlation with the anxiety and depression subscales measured by the © 2014 Wiley Publishing Asia Pty Ltd
CM:HADS, as well as the mental health scale assessed by the CM:SF-36. Given that these correlations were in the predicated directions, the CM:MHI was valid in measuring the respective intended constructs of mental health.33 The construct validity of CM:MHI was further supported by the results of known-groups comparison. In particular, the patients with comorbidity of heart failure scored significantly worse than those without heart failure, indicating the ability of CM:MHI to differentiate the mental health of patients with and without heart failure.6 The results of CFA further supported the construct validity of the CM:MHI as the goodness of fit indexes supported the convergence of internal factors structure of the translated instrument with the one purported by its original version.13 To conclude, in spite of the evidence of the rising prevalence of CHD in Mainland China, very few linguistically relevant measures are available for measuring the
Psychometrics of Mental Health Inventory
important outcome indicator of mental health for this expanding group of patients. This study ascertained the psychometric properties of the CM:MHI when used in the Chinese context, especially used for the Chinese-speaking patients with CHD. The CM:MHI would serve as a reliable and valid measure for the outcome of mental health intervention studies with Chinese CHD patients. In the clinical and community setting, this scale can be used by Chinese health-care professionals any time to screen the psychological status (e.g. anxiety, depression) of CHD patients. This information can help health-care professionals make better clinical decisions in the treatment of their patients. However, the convenience sampling used in our study might limit the generalizability of the results.33 Future studies might be conducted to examine the applicability of CM:MHI in other disease groups.
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ACKNOWLEDGEMENTS This is a self-funded study. The authors greatly appreciate the patients who participated in this study. 13
DECLARATION OF CONFLICT OF INTEREST The authors declare that there is no conflict of interest.
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with myocardial infarction. Journal of Preventive Cardiology 2014; 21: 318–326. Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of stress. Lancet 2007; 307: 1089–1100. Dimsdale JE. Psychological stress and cardiovascular disease. Journal of the American College of Cardiology 2008; 51: 1237–1246. Pan A, Rexrode KM. Taking psychological well-being to heart. Canadian Medical Association Journal 2012; 184: 1453– 1454. Dickens C, Cherrington A, McGowan L. Depression and health-related quality of life in people with coronary heart disease: A systemic review. European Journal of Cardiovascular Nursing 2012; 11: 265–275. Davidson KW, Mostofsky E, Whang W. Don’t worry, be happy: Positive affect and reduced 10-year incident coronary heart disease: The Canadian Nova Scotia Health Survey. European Heart Journal 2010; 31: 1065– 1070. Lee DT, Choi KC, Chair SY et al. Psychological distress mediates the effects of socio-demographic and clinical characteristics on the physical health component of healthrelated quality of life in patients with coronary heart disease. European Journal of Preventive Cardiology 2014; 21: 107–116. Veit CT, Ware JE. The structure of psychological distress and well-being in general populations. Journal of Consulting and Clinical Psychology 1938; 51: 730–742. Manne S, Schnoll R. Measuring cancer patients’ psychological distress and well-being: A factor analytic assessment of the mental health inventory. Psychological Assessment 2001; 13: 99–109. Irish J, Sandhu N, Simpson C et al. Quality of life in patients with maxillectomy prostheses. Head and Neck 2009; 31: 813–821. Inbar C, Ety B, Ayala H, Tamer P. The mental health of breast cancer survivors and their adolescent daughters. Psycho-Oncology 2013; 22: 1236–1241. Leibovici V, Canetti L, Yahalomi S et al. Wellbeing, psychopathology and coping strategies in psoriasis compared with atopic dermatitis: A controlled study. Journal of the European Academy of Dermatology and Venereology 2010; 24: 897–903. Ostroff JS, Woolverton KS, Berry C, Lesko LM. Use of the mental health inventory with adolescents: A secondary analysis of the rand health insurance study. Psychological Assessment 1996; 8: 105–107. Cuijpers P, Smits N, Donker T et al. Screening for mood and anxiety disorders with the five-item, the three-item, and the two-item Mental Health Inventory. Psychiatry Research 2009; 168: 250–255. Meybodi FA, Saeedi Z, Behjati Z et al. Reliability and validity of a Farsi version of 18-item Mental Health Inventory. © 2014 Wiley Publishing Asia Pty Ltd
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Procedia—Social and Behavioural Sciences 2011; 30: 1425– 1429. Liang J, Wu SC, Krause NM et al. The structure of the mental health inventory among Chinese in Taiwan. Medical Care 1992; 30: 659–676. McBride-Chang C, Chow BWY, Zhong Y et al. Chinese character acquisition and visual skills in two Chinese scripts. Reading and Writing 2005; 18: 99–128. Brislin RW. The wording and translation of research instrument. In: Lonner WJ, Berry JW (eds). Field Methods in Cross-Cultural Research. Beverly Hills, CA, USA: Sage Publications, 1986; 137–164. Yu SF, Lee TF, Woo J. Issues and challenges of instrument translation. Western Journal of Nursing Research 2004; 26: 307–320. Dixon JK. Exploratory factor analysis. In: Munro BH (ed.). Statistical Methods for Health Care Research, 5th edn. Philadelphia: Lippincott Williams & Wilkins, 2005; 321– 351. Ware JE, Kosinske M, Gandek B. SF-36 Health Survey: Manual and Interpretation Guide. Lincoln, RI: QualityMetric Incorporated, 2003.
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27 Andrersen EM, Meyers AR. Health-related quality of life outcome measures. Archives of Physical Medicine and Rehabilitation 2000; 81 (Suppl. 2): S30–S45. 28 Wang W, Lopez V, Chair SY, Thompson DR. The psychometric properties of the Chinese version of the SF-36 health survey in patients with myocardial infarction in mainland China. Quality of Life Research 2006; 15: 1525–1531. 29 Zigmond AS, Snaith RR. The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica 1983; 67: 361–370. 30 Wang W, Chair SY, Thompson DR, Twinn SF. Psychometric evaluation of the Chinese version of the Hospital Anxiety and Depression Scale in patients with coronary heart disease. Journal of Clinical Nursing 2009; 18: 1908–1915. 31 Scientific Advisory Committee of the Medical Outcomes Trust. Assessing health status and quality-of-life instruments: Attributes and review criteria. Quality of Life Research 2002; 11: 193–205. 32 Brown TA. Confirmatory Factor Analysis for Applied Research. New York: A Division of Guilford Publications, Inc, 2006. 33 Polit DF, Beck CT. Nursing Research: Appraising Evidence for Nursing Practice, 9th edn. Philadelphia: Lippincott Williams & Wilkins, 2009.
International Journal of Nursing Practice 2015; 21: 913–922
RESEARCH PAPER
Psychometric testing of the Chinese Mandarin version of the Mental Health Inventory among Chinese patients with coronary heart disease in Mainland China Meili Liu BSN RN Senior Nurse, Cardiovascular Department, First Affiliated Hospital of Medical College of Xi’an Jiaotong University, Xi’an, Shaanxi, China
Aloysius Chow BPsych (Hons) Research Assistant, Alice Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Ying Lau PhD RN Assistant Professor, Alice Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Hong-Gu He, PhD RN Assistant Professor, Alice Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Wenru Wang PhD RN Assistant Professor, Alice Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Accepted for publication August 2013 Liu M, Chow A, Lau Y, He H-G, Wang W. International Journal of Nursing Practice 2015; 21: 913–922 Psychometric testing of the Chinese Mandarin version of the Mental Health Inventory among Chinese patients with coronary heart disease in Mainland China This study aimed to develop a Chinese Mandarin version of the Mental Health Inventory (CM:MHI). The English version MHI was translated into Chinese (simple Chinese character) using the forward-backward translation method while establishing the semantic equivalence and content validity. A convenience sample of 204 coronary heart disease (CHD) patients was recruited to evaluate the internal consistency, concurrent validity and construct validity of the CM:MHI. Forty patients completed the CM:MHI to evaluate the test–retest reliability after 2 weeks. The CM:MHI demonstrated good semantic equivalent rate (92%) and satisfactory content validity index (0.91). The internal consistency was acceptable for total and all subscales with Cronbach’s alpha greater than 0.70, with the exception of the subscale of Emotional Ties (Cronbach’s alpha = 0.64). The test–retest reliability was also satisfactory with intraclass correlation coefficients higher than 0.75. The concurrent validity was acceptable with significantly strong correlations
Correspondence: Wenru Wang, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, Level 2, Clinical Research Centre, Block MD 11,10 Medical Drive, Singapore 117597. Email: [email protected] doi:10.1111/ijn.12301
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between the CM:MHI and the Chinese Mandarin versions of Short Form 36 Health survey and Hospital Anxiety and Depression Scale. Confirmatory factor analysis further supported the five-factor structure of the CM:MHI. The CM:MHI demonstrated to be a valid and reliable measure for assessing psychological distress and well-being in Chinese-speaking CHD patients. Key words: Chinese, cross-cultural validation, heart disease, psychological distress, psychological well-being.
INTRODUCTION
The growing rates of industrialization and urbanization in Mainland China have inadvertently introduced a Westernized lifestyle into the lives of the Chinese people. Unfortunately, this Western influence on the diets and lifestyles of the Chinese people, contributed to an increased incidence of health problems like diabetes, hypertension and obesity.1 These health problems are also risk factors for coronary heart disease (CHD), which is currently one of the leading causes of physical disability and decreased quality of life worldwide.2 Together with an ageing population and increasing internal migration from rural to Westernized urban cities, the prevalence of CHD in Mainland China is expected to increase in the near future. This concern is supported by a computer simulation model, the CHD Policy Model-China, which looked at how urbanization would affect Mainland China.3 From this model, it was reported that the incidence of CHD in Mainland China is expected to increase by two times between 2010 and 2030.3 Several studies have been conducted in mainland China to explore the experiences of Chinese CHD patients, and the results consistently indicated that the patients were going through a ‘life-threatening illness’, adjusting to a different lifestyle because of CHD and ‘help-seeking behaviour’.2,4–6 Affected individuals are also faced with the threat of family life alteration, strained marital relationships, economic burden and fewer job opportunities.4 All these lead to frustration, despair, loss of hope and impaired quality of life.4–6 These also highlight that Chinese CHD patients experience a significant amount of psychological stress. It has been documented that stress adversely affects the cardiovascular system because stress can cause an imbalance to our sympathetic– parasympathetic system and modify our hypothalamic– pituitary–adrenal axis which are responsible for regulating many of our bodily functions, such as the cardiovascular system.7–10 A large sample prospective study reported that participants who actively exhibited positive affects had a lower risk of developing CHD over a 10 year period.11 © 2014 Wiley Publishing Asia Pty Ltd
Davidson and her colleagues suggested that the positive affect had an indirect effect on the participants, such as increased quality of sleep and decreased number of people who smoked.11 Therefore, health-care professionals ought to be encouraged to help CHD patients manage stress better to reduce the effect of this risk factor, as CHD patients tend to report experiencing a significant amount of psychological distress.12 To allocate resources efficiently, it is important for health-care professionals to have an objective and accurate instrument to assess for psychological distress in CHD patients. The Mental Health Inventory (MHI) is such an instrument as it can assess both psychological distress and well-being .13 While developing the MHI, Veit and Ware proposed that assessing for well-being would provide a more accurate measurement of the mental state of an individual, as compared with merely measuring psychological distress alone.13 The MHI has been widely used with respectable psychometrical standards reported for different types of chronic diseases like cancer,14–16 dermatological diseases,17 for use with adolescents,18 and there are several abridged versions of the MHI as well.19 To be more accessible, the MHI has also been translated into different languages like Farsi20 and Chinese.21 A simplified Chinese version of the MHI will be beneficial for use in Mainland China, considering the vast number of CHD patients currently and in the near future.2,3 However, the current Chinese version is presented in traditional Chinese, and simplified Chinese is used in Mainland China. There are cognitive differences (e.g. visual recognition and mental processing) when reading the written characters of traditional and of simplified Chinese.22 In addition, the current traditional Chinese version of the MHI was validated with a sample from Taiwan,21 where the culture, economic and social background is different from Mainland China. Therefore, a simplified Chinese version will be better received by both health-care professionals and CHD patients in Mainland China, and provide a more accurate assessment of psychological distress and well-being.
Psychometrics of Mental Health Inventory
METHODS This study evaluating the psychometric properties of the Chinese Mandarin version of the MHI (CM:MHI) was conducted in two phases. The aims of the first phase were to translate the original English version of the MHI into Chinese Mandarin (simple Chinese characters), and thereafter examine the semantic equivalent and content validity of the CM:MHI. The second phase aimed at examining the internal consistency, test–retest reliability, concurrent validity and factor structure of this translated assessment tool.
PHASE ONE: TRANSLATION AND DEVELOPMENT OF THE CM:MHI The forward-backward translation method was used in this study.23 A bilingual research assistant translated the English MHI into simplified Chinese. Thereafter, an independent translator conducted a back-translation into English. The focus of the translation was on the conceptual equivalence of the items.23 Conceptual equivalence refers to whether the concepts of the phenomena being studied possessed the same conceptual meanings in both cultures.24 After the translation discrepancies in the CM:MHI had been clarified, the resulting version was examined for semantic equivalence. Ten bilingual health-care professionals were invited to evaluate the equivalence of translation between each item of the original English and translated Chinese version of MHI using a 4-point rating form (1 = not equivalent, 2 = somewhat equivalent, 3 = quite equivalent and 4 = most equivalent). Next, an expert panel consisting of two physicians, one psychologist, four nurse specialists and three nurse educators were recruited to provide their feedback on the cultural relevance and content validity of the CM:MHI for use in Mainland China. This expert panel was also asked to evaluate the CM:MHI in terms of cultural relevance and content validity as a measure for psychological distress and well-being for the Chinese population with CHD using a 4-point rating scale (1 = not relevant, 2 = somewhat relevant, 3 = relevant and 4 = very relevant).
PHASE TWO: PSYCHOMETRIC PROPERTIES TESTING In the second phase of the study, a convenience sample of 204 patients with CHD was recruited from two general public hospitals in Xi’an city, People’s Republic of China. The inclusion criteria included: (i) a diagnosis of CHD; (ii)
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being able to read simple Chinese characters; (iii) have no evidence of current or past psychiatric illness; and (iv) have no severe mobility problems. In accordance with the recommendation of 5–10 subjects per questionnaire item for the assurance of the accuracy in estimating the model parameters,25 a minimum sample size of 190 was needed for the 38-item CM:MHI. A total of 204 subjects were recruited to participate in this study eventually. Permission to conduct the study was sought from the ethical committees of two hospitals. With consent obtained from the participants, a research assistant administered the instrument to them at both hospitals. Each interview required approximately 20 min. To investigate the test–retest reliability, 40 subjects were randomly selected from the primary sample and asked to complete the CM:MHI again in 2 weeks.
Instruments The MHI
The MHI has been widely used to measure the psychological distress and well-being in both general populations and patients with chronic disease.13–16 It consists of 38 items and is divided into two higher-order subscales: Psychological Distress and Psychological Well-being. Psychological Distress is divided into subscales labelled Anxiety (10 items), Depression (5 items) and Loss of Behavioral/Emotional Control (9 items). Psychological Well-being is further divided into second-order subscales of Emotional Ties (3 items) and General Positive Affect (11 items). All of the items are scored on a six-point scale (i.e. range 1–6), except two (items 9 and 28) which are scored on a fivepoint scale (i.e. range 1–5). For the Psychological Distress subscale, including Anxiety, Depression and Loss of Behavioral/Emotional Control, higher score implies greater psychological distress. Whereas in the Psychological Well-being subscale, including General Positive Affect and Emotional Ties, higher score indicates better psychological well-being. The Cronbach’s alphas for the Psychological Distress and Psychological Well-being were reported as 0.94 and 0.92, respectively, and those of the five subscales ranged between 0.81 and 0.92.13
The Chinese Mandarin version of the Short Form-36 health survey (CM:SF-36)
The SF-36, a robust and widely used scale for the measurement of health status, comprises of 36 items in eight subscales (i.e. physical functioning, role functional © 2014 Wiley Publishing Asia Pty Ltd
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physical, role functioning emotional, mental health, social functioning, bodily pain, general health perceptions and vitality).26 Each subscale score ranges from 0 to 100, with a higher score indicating better quality of life.26 The subscale scores can be divided into physical and mental component summary scales. The SF-36 is psychometrically sound in numerous population samples.27 The CM:SF-36 has demonstrated good validity and reliability with acceptable internal consistency for all subscales (Cronbach’s alpha 0.64–0.93) and the test–retest reliability being adequate with the intraclass correlation coefficient (ICC) of 0.75 for all subscales.28
The Chinese Mandarin version of Hospital Anxiety and Depression Scale (CM:HADS)
The HADS is a 14-item questionnaire and can be divided evenly into the anxiety and depression subscales.29 The items are rated on a four-point scale with a range from 0 to 3 with fixed response statements, whereby a higher score represents a higher level of psychological distress. The CM:HADS was reported to have good reliability and validity.30 Cronbach’s alphas for the total scale, anxiety and depression subscales were found to be 0.85, 0.79 and 0.79, respectively.30
The demographic and clinical data sheet
A demographic and clinical data sheet was developed to collate data regarding the participant’s demographic variables and clinical information.
Data analysis IBM SPSS Statistics version 20.0 (Armonk, NY, USA) was used for analysing the psychometric properties, such as internal consistency, test–retest reliability, concurrent validity and factor structure. The internal consistency of scale was tested using the Cronbach’s alpha and itemto-total correlations. The internal consistency of each subscale was accepted for group comparison if the Cronbach’s alpha coefficient was greater than 0.7. The test–retest reliability was evaluated using ICC, and r > 0.75 suggested adequate stability.31 A Pearson correlation test was used to evaluate the concurrent validity of CM:MHI with the CM:SF-36 and CM:HADS. A P-value of 0.05 was accepted as a significant level of correlation. A confirmatory factor analysis (CFA) was performed using Amos 18.0 (SPSS Inc., Chicago, IL, USA) to examine the factor structure of CM:MHI. The overall data-model fitness of CM:MHI was examined by the © 2014 Wiley Publishing Asia Pty Ltd
commonly used ‘goodness of fit’ indices. These included the chi-square/degree of freedom ration (χ2/df), the normal and non-normal fit indices (NFI and NNFI), comparative fit index (CFI), root mean square error of approximation (RMSEA), and incremental fit index (IFI). Model fit is deemed acceptable with χ2/df ≤ 3, NNFI > 0.9, CFI > 0.9, RMSEA < 0.08 and IFI > 0.9.32
RESULTS Semantic equivalence and content validity With regard to the semantic equivalence, all the items were rated by at least 80% of the raters as having ‘quite equivalent’ or ‘most equivalent’, with the average equivalent rate being 92%, indicating that the Chinese Mandarin version was a correct refection of the English version. For the content validity, the expert panel rated that all 38 items of the CM:MHI are culturally relevant for Chinese patients with CHD. The content validity index, which is the percentage calculated based on the total items rated by the experts as either 3 or 4,33 was 0.91, indicating a good content validity.
Sample A total of 246 CHD patients were approached, and 204 (82.9%) of them were recruited from the cardiac outpatient clinic of two general public hospitals in Xi’an City of China for testing the psychometric properties of the CM:MHI. There were 139 (68.1%) men and 65 (31.9%) women. The mean age of the subjects was 63.1 years (SD = 11.8, range 29–88). Half of the subjects had high cholesterol and nearly one fourth had the comorbidity of heart failure (Table 1).
Internal consistency and reliability The internal consistency of the two higher-order subscales and the five second-order subscales as well as the total scale was satisfactory, with Cronbach’s alpha > 0.70, with the exception of the subscale of Emotional Ties (Cronbach’s alpha = 0.64). The correlations between items and their respective subscale were significantly high, with Pearson correlation coefficients ranging between 0.43 and 0.88. All of the ICCs of the total and subscale scores were higher than 0.75, indicating an adequate test– retest reliability. The Cronbach’s alphas, item-total correlations and ICCs of each subscale are shown in Table 2.
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Table 1 Sociodemographic and clinical characteristics of the sample (n = 204) Variable Sex Male Female Marital status Married Not married† Educational level (years) Primary or less (< 6) Secondary (7–13) Tertiary (> 13) Occupation Full-time job Part-time and retired Smoking status Current smoker Ex-smoker Coronary family history Yes No High cholesterol Yes No Hypertension Yes No Comorbidity with heart failure Yes No Comorbidity with diabetes Yes No
Frequency
Percentage
139 65
68.1 31.9
185 19
90.7 9.3
47 109 48
23.1 53.4 23.5
135 69
66.2 33.8
30 96
14.7 47.1
62 142
30.4 69.6
102 102
50.0 50.0
135 69
66.2 33.8
45 159
22.1 77.9
47 157
23.0 77.0
†
Not married includes single, divorced or widowed.
Concurrent validity There were significant correlations between the CM:MHI and the relevant dimensions of the CM:SF-36 and the CM:HADS (Table 3). The results of Pearson productmoment correlation coefficients indicated that the concurrent validity for the CM:MHI was confirmed with significant and moderate/high correlations between the subscales of the CM:MHI and the CM:HADS anxiety (r = 0.33–0.89, P < 0.01) and depression (r = − 0.32 to 0.76, P < 0.01) scales. There were significant and moderate/high correlations between the CM:SF-36
mental component subscale and all CM:MHI subscales (r = 0.22 to − 0.64, P < 0.01). The CM:SF-36 physical component subscale had also significant correlations with the CM:MHI subscales of Anxiety (r = − 0.24, P < 0.01), Depression (r = − 0.17, P < 0.05) and General Positive Affect (r = 0.25, P < 0.01).
Construct validity: Known-groups comparison The results of know-groups comparison lent further evidence to support the construct validity of CM:MHI. Comparison of the mean scores of the subscales of the CM:MHI with gender, age and comorbidities with heart failure and diabetes is shown in Table 4. The results indicated that women had significantly lower scores on Loss of Behavioral/ Emotional control (P < 0.05), whereas older patients scored significantly lower on the Emotional Ties (P < 0.05). Patients with comorbidity with heart failure had significantly higher score of psychological distress (P < 0.05) and lower score of psychological well-being (P < 0.05). However, no any significant differences were found between the patients with or without comorbidity with diabetes (P > 0.05).
Factor structure The goodness of fit indices demonstrated a better data model fit with the χ2/df being 2.74, the NFI being 0.86, NNFI being 0.90, CFI being 0.91 and RMSEA being 0.061. For the parameter estimation, all the items loaded significantly onto their respective factor, with factor loading ranging from 0.41 to 0.90 (Fig. 1). The findings therefore affirmed the five-factor structure of the CM:MHI and added evidence of its factor structure. In addition, the correlations between the factors of Anxiety, Depression and Loss of Behavioral/Emotional Control, as well as the correlation between the factors of General Positive Affect and Emotional Ties were very strong (r > 0.86). This indicates that the respective subscales were measuring the similar sub-construct—psychological distress and well-being.
DISCUSSION Although the MHI has been widely used to assess the mental health in both general population and individuals with chronic disease,13–16 including patients with CHD,12 this is the first study to report the psychometric properties of the Chinese Mandarin version of the MHI (simple © 2014 Wiley Publishing Asia Pty Ltd
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Table 2 Internal consistency (item-to-total correlations and Cronbach’s alpha coefficients) and test–retest reliability of the CM:MHI Domain
Psychological distress Anxiety Item 3. Nervous and jumpy Item 11. Very nervous person Item 13. Felt tense or high-strung Item 15. Hands shake when doing things Item 22. Relax without difficulty Item 25. Bothered by nervousness Item 29. Restless, fidgety, impatient Item 32. Rattled, upset, or flustered Item 33. Anxious, worried Item 35. Difficulty trying to calm down Depression Item 9. Felt depressed Item 19. Downhearted and blue Item 30. Moody, brooded about things Item 36. Low or very low spirits Item 38. Strain, stress, pressure Loss of Behavioral/Emotional Control Item 8. Concern about losing control of mind Item 14. Control of behavior, thoughts, feelings Item 16. Nothing to look forward to Item 18. Felt emotionally stable Item 20. Felt like crying Item 21. Better off if dead Item 24. Nothing turns out as wanted Item 27. Down in the dumps Item 28. Think about taking own life Psychological Well-being General Positive Affect Item 1. Happy, satisfied, or pleased Item 4. Future hopeful, promising Item 5. Daily life interesting Item 6. Relaxed and free of tension Item 7. Generally enjoyed things Item 12. Expect an interesting day Item 17. Felt calm and peaceful Item 26. Living a wonderful adventure Item 31. Felt cheerful, lighthearted Item 34. Happy person Item 37. Wake up fresh, rested Emotional Ties Item 2. Time felt lonely Item 10. Felt loved and wanted. Item 23. Love relations full, complete Overall score
Item-to-total correlation (n = 204)
Intraclass coefficient (n = 40)
0.90 0.73
0.86 0.84
0.81
0.79
0.77
0.78
0.83 0.76
0.89 0.81
0.64
0.82
0.81
0.89
0.57 0.71 0.77 0.47 0.50 0.80 0.69 0.60 0.76 0.60 0.77 0.86 0.74 0.88 0.40 0.53 0.78 0.53 0.53 0.55 0.53 0.46 0.59 0.48
0.60 0.73 0.81 0.59 0.82 0.71 0.67 0.61 0.76 0.79 0.65 0.43 0.73 0.58
CM:MHI, Chinese Mandarin version of the Mental Health Inventory.
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Cronbach’s alpha (n = 204)
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Table 3 Pearson correlations of the association between the CM:MHI and the CM:SF-36 domains and the CM:HADS anxiety and depression subscales (n = 204) Domain
CM:SF-36 SF-36 PCS SF-36 MCS CM:HADS Anxiety subscale Depression subscale
CM:MHI Anxiety
Depression
Loss of Behavioral/ Emotional Control
− 0.24** − 0.54**
− 0.17* − 0.64*
− 0.13 − 0.53**
0.25** 0.55**
0.05 0.22**
0.33** 0.54**
− 0.45** − 0.32**
− 0.47** − 0.43**
0.89** 0.68**
0.61** 0.76**
General Positive Affect
Emotional Ties
* Significant at 0.05, ** Significant at 0.01. CM:HADS, Chinese Mandarin version of Hospital Anxiety and Depression Scale ; CM:MHI, Chinese Mandarin version of the Mental Health Inventory; CM:SF-36, Chinese Mandarin version of the Short Form-36 health survey; MCS, mental component subscale; PCS, physical component subscale. Table 4 Comparison of scale means of various dimensions of CM:MHI by gender, age and comorbidities with heart failure and diabetes Variable
Gender Male (n = 139) Female (n = 65) P-value Age < 65 years (n = 112) ≥ 65 years (n = 92) P-value Comorbidity with heart failure No (n = 159) Yes (n = 45) P-value Comorbidity with diabetes No (n = 157) Yes (n = 47) P-value
Anxiety
Depression Loss of Behavioral/ General Emotional Emotional control positive affect ties
Psychological Psychological distress well-being
25.2 ± 6.8 21.4 ± 3.6 34.4 ± 3.1 26.9 ± 6.9 20.8 ± 3.5 33.4 ± 3.5 0.107 0.319 0.033*
30.7 ± 8.4 32.2 ± 7.8 0.229
12.4 ± 2.7 81.0 ± 4.5 12.0 ± 2.8 81.1 ± 4.5 0.308 0.872
43.2 ± 6.6 44.2 ± 6.2 0.270
25.7 ± 6.5 21.1 ± 3.4 34.2 ± 3.1 25.9 ± 7.4 21.4 ± 3.7 33.8 ± 3.4 0.820 0.550 0.416
30.9 ± 8.4 31.7 ± 8.0 0.489
12.7 ± 2.7 81.0 ± 4.1 11.8 ± 2.8 81.1 ± 5.0 0.032* 0.845
43.5 ± 6.6 43.5 ± 6.3 0.959
25.3 ± 6.8 21.5 ± 3.5 34.1 ± 3.4 28.3 ± 7.0 23.4 ± 3.9 35.9 ± 2.7 0.001** 0.049* 0.214
33.5 ± 8.0 30.6 ± 8.6 0.038*
12.4 ± 2.7 80.9 ± 4.6 11.9 ± 2.9 84.5 ± 4.0 0.280 0.014*
45.2 ± 6.3 42.0 ± 6.3 0.045*
25.5 ± 6.6 21.3 ± 3.5 34.1 ± 3.4 26.7 ± 7.8 22.0 ± 3.6 35.8 ± 2.7 0.315 0.630 0.541
31.1 ± 8.3 31.5 ± 7.8 0.781
12.4 ± 2.8 80.1 ± 4.1 11.9 ± 2.6 81.5 ± 5.3 0.358 0.458
43.8 ± 6.5 43.2 ± 6.5 0.967
** Significance at the level of P < 0.01. * Significance at the level of P < 0.05. CM:MHI, Chinese Mandarin version of the Mental Health Inventory.
Chinese characters) among Chinese population with CHD in Mainland China. The results of our study demonstrated the good psychometric properties of the CM:MHI in terms of semantic equivalence, content validity, internal consistency, test–retest reliability and construct validity.
The forward and backward translation process recommended by Brislin was rigorously carried out,23 and this ensured semantic, cultural equivalence and content validity. Evidence for the internal consistency of CM:MHI was demonstrated by the high values of Cronbach’s alpha of © 2014 Wiley Publishing Asia Pty Ltd
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Figure 1. Confirmatory factor analysis of the CM:MHI.
the overall scale, two first-order subscales and the secondorder subscales with the exception of the subscale of Emotional Ties (r = 0.64). The relative lower Cronbach’s alpha for the subscale of Emotional Ties indicates that the internal consistency of this subscale might not be acceptable. However, this would not greatly impact the utilization of the scale as the internal consistency for the overall scale is satisfactory.33 The results of the item analysis further indicated the homogeneity of the items to its own scale, indicating the internal consistency of their respective items in measuring the sub-constructs.31 As for stability, the results from 40 participants demonstrated satisfactory test–retest reliability for the overall scale and all sub-scales, indicating the stability of the instrument in measuring the constructs. The concurrent validity of the CM:MHI was established by its significant and strong correlation with the anxiety and depression subscales measured by the © 2014 Wiley Publishing Asia Pty Ltd
CM:HADS, as well as the mental health scale assessed by the CM:SF-36. Given that these correlations were in the predicated directions, the CM:MHI was valid in measuring the respective intended constructs of mental health.33 The construct validity of CM:MHI was further supported by the results of known-groups comparison. In particular, the patients with comorbidity of heart failure scored significantly worse than those without heart failure, indicating the ability of CM:MHI to differentiate the mental health of patients with and without heart failure.6 The results of CFA further supported the construct validity of the CM:MHI as the goodness of fit indexes supported the convergence of internal factors structure of the translated instrument with the one purported by its original version.13 To conclude, in spite of the evidence of the rising prevalence of CHD in Mainland China, very few linguistically relevant measures are available for measuring the
Psychometrics of Mental Health Inventory
important outcome indicator of mental health for this expanding group of patients. This study ascertained the psychometric properties of the CM:MHI when used in the Chinese context, especially used for the Chinese-speaking patients with CHD. The CM:MHI would serve as a reliable and valid measure for the outcome of mental health intervention studies with Chinese CHD patients. In the clinical and community setting, this scale can be used by Chinese health-care professionals any time to screen the psychological status (e.g. anxiety, depression) of CHD patients. This information can help health-care professionals make better clinical decisions in the treatment of their patients. However, the convenience sampling used in our study might limit the generalizability of the results.33 Future studies might be conducted to examine the applicability of CM:MHI in other disease groups.
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ACKNOWLEDGEMENTS This is a self-funded study. The authors greatly appreciate the patients who participated in this study. 13
DECLARATION OF CONFLICT OF INTEREST The authors declare that there is no conflict of interest.
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