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Translation and psychometric evaluation of the Chinese version of the Heart Failure-Specific Health Literacy Scale
International Journal of Nursing Sciences xxx (2016) 1e5
Contents lists available at ScienceDirect
H O S T E D BY
International Journal of Nursing Sciences journal homepage: http://www.elsevier.com/journals/international-journal-ofnursing-sciences/2352-0132
ORIGINAL ARTICLE
Translation and psychometric evaluation of the Chinese version of the Heart Failure-Specific Health Literacy Scale Meng Yue a, Lijun Zhang b, Yuanyuan Lu c, Changde Jin a, * a
Nursing College, Tianjin University of Traditional Chinese Medicine, Tianjin, China Cardiology department, Tianjin People's Hospital Tianjin Union Medical Center, Tianjin, China c Cardiology department, Tianjin First Center Hospital, Tianjin, China b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 August 2016 Received in revised form 31 October 2016 Accepted 2 November 2016 Available online xxx
Objective: Health literacy is closely associated with self-care behaviors in heart-failure patient. A reliable, valid, and practical measuring tool would evaluated the level of health literacy in Chinese patients with heart failure, and provide evidence for individualized education. Aim of this study was to translate Heart Failure-Specific Health Literacy Scale (HF-Specific HL Scale) into Chinese and test the reliability and validity of the Chinese version. Methods: The original HF-specific HL scale was translated into Chinese and modified for cultural adaption. Totally 164 HF inpatients were investigated with the Chinese version of HF-specific HL scale. To test the reliability and validity of the scale, item analysis, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and correlation analysis were conducted. Result: Cronbach's a value for the scale is 0.87; the correlation coefficients between each item and the total score ranged from 0.61 to 0.91. Three factors was extracted by EFA, which could explain 64.62% of the total variance. The result of CFA also showed that the scale demonstrated an acceptable model fit. The scale was significantly correlated with the Chinese version of the Heart Failure Knowledge Test (C-HFKT). Conclusion: The Chinese version of HF-specific HL scale is reliable and valid, and is suitable for assessment of HL in Chinese HF patients. © 2016 Chinese Nursing Association. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Health literacy Heart failure Scale Psychometric evaluation
1. Introduction Heart failure (HF) is the end of the development prognosis for many cardiovascular disease. For HF patients, the activity endurance has been limited, and the quality of life became worse [1]. In developed countries, the morbidity of HF is more than 10% among population who are older than 65 years old and more than 5.7 million people experience HF in the US [2,3]. In developing countries, HF was characterized by high morbidity, high mortality, and long hospital stay [4]. It has been reported that four million people in China has been suffered from HF [5]. Patients experiencing HF not only must adhere to long-term and complex medication, but also must change their lifestyle. Improving the self-care behavior of HF patient is the effective way to prevent HF patients from frequently readmission, it helps
* Corresponding author. E-mail address: [email protected] (C. Jin). Peer review under responsibility of Chinese Nursing Association.
reduce the cost and improve their quality of life [6,7]. Acquiring and applying the related health care information is an important step to improve self-care behaviors for HF patients. With the development of network information technology, the approach individuals acquire information has not been limited to health care professionals or medical care personnel. More and more patients obtain information from Internet and relevant media. However, information patients seeking voluntarily may be false, people who trust and obey it would cause a tragedy. So the ability called health literacy (HL) including seek, understand, critically evaluate, and apply information becomes essential. Recent research suggested that HL was associated with self-care behaviors among HF patient [8]. As a consequence, heighten the level of HL contributes to the improvement of HF patients' self-care behaviors, decrease of hospitalization rate and readmission rate. Toward targeting public health efforts to improve self-care behaviors of HF patient, develop an instrument to measure their HL level is necessary [9]. Netbeam [10] proposed the HL concept based on his/her health promotion theory. The HL concept contains three sections: functional HL, interactive HL and critical HL. Functional HL refers to the
http://dx.doi.org/10.1016/j.ijnss.2016.11.004 2352-0132/© 2016 Chinese Nursing Association. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Yue M, et al., Translation and psychometric evaluation of the Chinese version of the Heart Failure-Specific Health Literacy Scale, International Journal of Nursing Sciences (2016), http://dx.doi.org/10.1016/j.ijnss.2016.11.004
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M. Yue et al. / International Journal of Nursing Sciences xxx (2016) 1e5
basic reading and writing skills. Interactive HL is an advanced skill compared to functional literacy which refers to extracting and understanding information in daily-life situations. Critical HL refers to the ability to analyze and utilize information, it represents the dominate of the disease state. Upon Netbeam's HL concept, specific HL scales focus on chronic disease such as diabetes, high blood pressure, and cancer have been developed [11e13]. To assess the HL level of HF patients, Shiho Matsuoka [14] developed the HF-specific HL scale, which comprises three dimensions and 12 items. This scale use four scoring options as following: 1 ¼ inapplicable; 2 ¼ rarely applicable; 3 ¼ sometimes applicable; and 4 ¼ strongly applicable. High scores correlated with high level of HL. Shiho Matsuoka applied the scale in outpatients, and the result confirmed that the reliability and validity of the scale were adequate. The specific scales focusing on certain disease or state could immediately and correctly reflect the condition and requirement of patients [15]. By translation, back-translation, and cultural adaptation the Chinese version HF-specific HL Scale and apply the scale, the aim of the study was to establish a Chinese version HF-specific HL Scale which is appropriate for HF patients in Mainland China, so as to provide scientific instrument to measure patients' HL level and take corresponding measures to improve HL levels on the basis of the results. 2. Methods 2.1. Study design and setting The study consisted of two phases. The first phase aimed to translate and revise the HF-specific HL Scale; the second phase was to test the reliability and validity of the Chinese version. The study was carried out in two hospitals in Tianjin. The inclusion criteria was as follows: diagnosis of HF; aged 18 years or above; NYHA (New York Heart Association Functional Classification) class III~IV. Patients who meet the following criteria were excluded: had physical disease or cognitive impairment (the score of Mini-Mental State Examination was lower than 2). In this study, the sample size was 10 times of the items number [16], then added 20% invalid questionnaires, thus the total sample size was 164. The researcher communicated with the respondents and explained the purpose, significance, and process of the survey. The patients were entitled to participate or withdraw the survey. Patients agreed to participate in the survey were enrolled. 2.2. Forward-translation, back-translation, and cultural adaptation of HF-specific HL scale After authorized by Shiho Matsuoka, we translated and revised the scale according to the procedure proposed by Brislin [17]. The scale was forward-translated and back-translated as follows. Firstly, two bilingual researchers including a clinic nurse major in HF care who has a master degree and one doctor who graduated from the UK translated the English version into Chinese version. Then, the result was recorded by another researcher and checked by a HF care expert; Thirdly, two other clinic nurses major in HF care who have master degree and didn't know the scale before back translated the scale. Cultural adaptation was performed by 8 experts, including two cardiac physicians, three clinic nurses major in HF care, and three health care experts. The experts were invited to revise the items which were not suited to the culture in Mainland China. After final version was confirmed, 8 experts rated the content validity with a 4-point Likert scale: 1 ¼ not relevant; 2 ¼ somewhat relevant; 3 ¼ quite relevant; 4 ¼ very relevant. Ten HF patients satisfied the inclusion criteria mentioned above
participated in a pilot study. Their intelligibility towards the items and completion time was obtained. 2.3. Instruments The day before hospital discharge, patients were asked to complete the questionnaires including HF-specific HL Scale and CHFKT. The clinical data was collected by the researcher according to the medical record. Instruction for filling in the questionnaires was introduced by one researcher. After retrieving the questionnaires, the researcher checked them in case some items were omitted. 2.3.1. Demographic and clinical data Demographic data included age, gender, education level, employment status, and income per month. Clinical data included etiology, NYHA classification and complication. 2.3.2. Chinese version of HF-specific HL scale HF-specific HL Scale is a self-report scale. The scale with 3 dimensions and 12 items. The score of each item ranges from 1 to 4. The total score of the scale is 36. 2.3.3. Chinese version of Heart Failure Knowledge Test (C-HFKT) The questionnaire investigates the knowledge about the case and symptom of HF, the adherence of low salt diet, the effect and side effect of their medicine, and lifestyle that should persist by HF patients [18]. The questionnaire consists of 12 choice questions and 1 fill-in-the-blank question. The score of each item is 1, and the total point of the test is 13. A high score indicates exact HF knowledge. Currently, this questionnaire has been broadly accepted in research [19e21]. 2.4. Data analysis Data was analysis with the Statistical Package for Social Science (SPSS) version 17.0 for windows and AMOS 18.0. Descriptive analysis was used for evaluate the demographic and clinical data. Psychometric properties of Chinese HF-specific HL Scale were reflected by validity and reliability. 2.4.1. Validity CVI was measured to evaluate the content validity of the HFspecific HL Scale. The construct validity of HF-specific HL Scale was assessed using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Kaiser Meyer Olkin Measure (KMO) of Sampling Adequacy and Bartlett's Test of Sphericity were calculated prior to performing EFA which would explore the dimensions in the scale. If the KMO was found to be greater than 0.6 [22] and the Bartlett's Test of Sphericity was significant, the data is suitable for principal components analysis [23]. We perform principal components analysis with oblique rotation for factor rotation to explore the factorial structure. The three-factor model for the HF-specific HL scale was tested through a CFA Model. The quality of fitness was assessed by Chi Square (c2/df), Comparative Fit Index (CFI), Goodness of Fit Index (GFI), Adjusted Goodness of Fit Index (AGFI), Normed Fit Index (NFI), and Root Mean Square Error of Approximation (RMSEA). If c2/df was less than 5.0 [24], CFI, GFI, AGFI, and NFI was higher than 0.9 [25], and RMSEA was lower than 0.08 [26], the model was considered to have acceptable fit. Criterion-related validity was examined by evaluating the correlation coefficient (Person relation analysis) between the scores of HF-specific HL Scale and C-HFKT. 2.4.2. Reliability The internal consistency was assessed by calculating the
Please cite this article in press as: Yue M, et al., Translation and psychometric evaluation of the Chinese version of the Heart Failure-Specific Health Literacy Scale, International Journal of Nursing Sciences (2016), http://dx.doi.org/10.1016/j.ijnss.2016.11.004
M. Yue et al. / International Journal of Nursing Sciences xxx (2016) 1e5
Cronbach's a values and the split-half reliability. The Cronbach's a value of the whole scale and three dimensions were measured. The split-half reliability was conducted by dividing the items into two sections according to the odevity of item numbers, and calculated the correlation coefficient of the two halves. Test-retest reliability were also assessed. 30 participants were randomly selected from the 164 participants, and they were reevaluated 4 weeks later when they came for a check-back. Data were analysed by Pearson relation analysis for testeretest reliability. The test-retest reliability was acceptable when the correlation coefficient was higher than 0.75 [27].
3
from hospitals”, because in Chinese Mainland, pharmacies only offer drugs and they do not have the right to prescribe. During the adaption, six experts insisted that item 8 and item 9 were supposed to be exchanged, because according to Netbeam's HL concept, item 8 belongs to critical HL, and item 9 belongs to interactive HL. To verify this hypothesis, the validity and reliability after exchanging the two items were calculated. In the pilot study, all patients could understand every item, their judgment towards the meaning of the scale accorded with the established purpose. It took about 3 minutes to complete the scale. 3.2. Psychometric properties of HF-specific HL scale
3. Results 3.1. Translation and cultural adaptation of the HF-specific HL scale The back-translated version was contrasted with the original version, the researcher realized that the term “shortness of breath” was back-translated into “dyspnea”, to our knowledge, the former was an informal expression and the latter was a specialized vocabulary. Considering that “dyspnea” denote a broader concept, this term was retained. When communicated with the patients, the researcher used “shortness of breath” and “labored breathing”, which realized the semantic equivalence. To adapting the medical environment in Chinese Mainland, the experts suggested that the statement “The prescriptions and pamphlets from hospitals and pharmacies” in item 1, item 2, and item 3 should be replaced by “The prescriptions and pamphlets Table 1 dThe result of KMO and Bartlett's Test the HF-specific HL scale (Chinese version). Item
Score
KMO of sampling adequacy Bartlett's test of sphericity
0.820 9642.164 503 0.000
Approx. Chi-Square df Sig.
3.2.1. Demographic and clinical data 164 inpatients treated at cardiology department were surveyed. The mean age of the patients was 58.02 (SD 15.25), the proportion of patients older than 60 was 52.4%. The majority of patients were males, 31.1% patients had received senior high school education. 54.2% patients were in NYHA class III and 45.8% were in NYHA IV. Among them, the common etiology was coronary heart disease, myocardiopathy, valvular disease, and pulmonary heart disease. 72.5% patients had one complication or less. 3.2.2. Validity Based on scores from experts, the sale-level CVI (S-CVI) was gotten by calculating the ratio of item number which scored 3 or 4 to item amount; divided the number of experts who scored 3 or 4 by total expert number, the item-level CVI (I-SVI) of each item was assessed. The result showed that the S-CVI was 0.879, and the I-SVI was in the range of 0.834e1.0. The KMO measure was 0.82, and Bartlett's Test of Sphericity was acceptable (P < 0.05) (Table 1), the result supported the suitability for EFA. The scree plot indicated 3 factors were extracted (Fig. 1), which accounted for 64.62% of the total variance, with the loading of variables on factors bigger than 0.79 (Table 2). The six fit indices for the CFA supported the three factor structure of HF-specific HL scale. Five out of six fit indices indicated acceptable fit, and the
Fig. 1. A scree plot illustrating the factor loading of the Chinese version of HF-specific HL scale.
Please cite this article in press as: Yue M, et al., Translation and psychometric evaluation of the Chinese version of the Heart Failure-Specific Health Literacy Scale, International Journal of Nursing Sciences (2016), http://dx.doi.org/10.1016/j.ijnss.2016.11.004
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M. Yue et al. / International Journal of Nursing Sciences xxx (2016) 1e5
Table 2 Factor loadings for the HF-specific HL scale (Chinese version). Item
Mean (SD)
1. 2. 3. 4. 5.
The prescriptions and pamphlets from hospitals are hard to read. There are terms that I do not understand in the prescriptions and pamphlets from hospitals. The content in the prescriptions and pamphlets from hospitals is hard to understand. It is difficult to write in handbooks and documents from hospitals and pharmacies. I have been able to have satisfactory conversations regarding heart failure with those close to me, including medical professionals. 6. I have been able to understand information regarding the treatment and symptoms of heart failure and everyday precautions. 7. I have notices changes in the symptoms of heart failure such as dyspnea, palpitations, and edema. 8. I have gathered knowledge on heart failure from television,radio, and Internet. 9. I have wondered whether the information regarding heart failure and its treatment is applicable to me. 10. I have had doubts regarding the credibility of information regarding heart failure and its treatment. 11. I have asked and checked whether information regarding heart and its treatment is accurate. 12. I have gathered information on hospitals and treatments to make my own decisions. Rotation sums of squared loading (Cumulative 100%)
Factor loading 1
2
3
2.97(0.87) 2.35(0.72) 2.69(0.88) 3.04(0.90) 2.91(0.79)
0.752 0.728 0.713 0.687 0.321
0.230 0.145 0.148 0.233 0.675
0.132 0.178 0.212 0.089 0.118
3.43(0.91)
0.201
0.622
0.276
3.25(0.83) 3.12(0.96) 3.04(0.89) 2.76(1.00) 2.48(0.79) 2.32(0.72)
0.239 0.127 0.217 0.364 0.103 0.228 54.578
0.605 0.553 0.411 0.112 0.147 0.216 62.575
0.281 0.405 0.546 0.687 0.741 0.643 76.499
The maximum factor loading of each item is presented with bold value.
remaining one were slightly below 0.90 (AGFI) (Table 3). Standardized parameter estimate for the structural equation modeling is showed in figure (Fig. 2). Pearson correlation between HF-specific HL scale and C-HFKT scores was 0.774 (P < 0.01). 3.2.3. Reliability As shown in Table 5, Cronbach's a value for the overall scale was 0.87, and Cronbach's a value for the 3 dimensions were 0.84, 0.72, and 0.69 respectively, indicating acceptable internal consistency. The Cronbach's a coefficient between each dimension and the scale ranged from 0.61 to 0.91 (Table 4). The split-half reliability of HFspecific HL Scale was 0.80, and the test-retest reliability was 0.79e0.94 (Table 5). 4. Discussion The present study demonstrated the application of HF-specific HL scale with good reliability and validity. The reliability of Chinese version HF-specific HL scale was higher than the original version, the reason may be that we exchanged the items 8 and item 9, which might fit the concept better, in addition, compared to the study before [14], we included patients who were in NYHA IV, so the condition of patients included in this study was more serious. Three components were extracted after EFA; which was consist with the original scale and Netbeam's HL concept [10]. Considering that there was not much difference between item 8 and item 9, further study was needed to confirm the adjustment. This study use C-HFKT scores as the criterion-related variable, which measure whether HF patients grasp relevant knowledge about HF [18]. The self-care behaviors in C-HFKT scores was embodied by HF-specific HL Scale. Positive statistically significant correlation were found between HF-specific HL Scale and C-HFKT scores which explain a good Criterion-related validity. Some limitations should be acknowledged in this study. The subjects enrolled in this study were inpatients, to explore the applicability of the Chinese version HF-specific HL Scale, outpatients and domiciliary HF patients should also be investigated in
Table 3 Result of confirmatory factor analysis for the three-factor model. Fit index
c
df
c /df
CFI
GFI
AGFI
NFI
RMSEA
Value
107.46
90.30
1.19
0.995
0.933
0.897
0.961
0.024
2
2
Fig. 2. Path diagram for the three-factor model with standardized parameter estimate.
the future study. Discriminant validity was not conducted in this study, and in order to improve the revision, qualitative research should be performed with the quantitative study.
5. Conclusion The Chinese version of HF-specific HL Scale, being reliable, valid and easy to use, is suitable to be adapted by clinical setting as a screening tool to recognize HF patients with low level of HL.
Table 4 Internal correlation matrix and the coefficient analysis between the scale and three dimensions.
Fictional literacy Interactive literacy Critical literacy HF-specific HL scale
Fictional HL
Interactive HL
Critical HL
1 0.45** 0.36* 0.72*
1 0.42* 0.61*
1 0.91**
**P < 0.01, *P < 0.05.
Please cite this article in press as: Yue M, et al., Translation and psychometric evaluation of the Chinese version of the Heart Failure-Specific Health Literacy Scale, International Journal of Nursing Sciences (2016), http://dx.doi.org/10.1016/j.ijnss.2016.11.004
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Table 5 Reliability test of the HF-specific HL scale and each dimension. Item
Fictional HL Interactive HL Critical HL HF-specific HL scale
Cronbach's a value
0.84 0.72 0.69 0.87
Test
Retest
Mean (SD)
Mean (SD)
12.03 12.26 10.97 35.26
12.08 12.20 10.93 35.21
Author contributions Yue and Jin conceived the study. Zhang and Lu collected the data. Yue and Jin analyses the data. Yue draft the manuscript. Conflicts of interest None declared. Acknowledgments The authors would like to thank Shiho Matsuoka, who offer the English version of HF-specific HL scale. The authors also thank the medical staff in Tianjin People's Hospital, Tianjin Union Medical Center, and Tianjin First Center Hospital. References [1] Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American college of cardiology foundation/American heart association task force on practice guidelines. Circulation 2013;128(16):1810e52. [2] Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics2016 update: a report from the American heart association. Circulation 2016;133(4):e38e60. [3] Ponikowski P, Voors AA, Anker SD, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2016;18(8):891e975. [4] Magana-Serrano JA, Almahmeed W, Gomez E, et al. Prevalence of heart failure with preserved ejection fraction in Latin American, middle Eastern, and North African regions in the I PREFER study (identification of patients with heart failure and PREserved systolic function: an epidemiological regional study). Am J Cardiol 2011;108(9):1289e96. [5] Zhou J, Cui X, Ge J. The epidemiological profile of heart failure patients in China. Zhonghua Xin Xue Guan Bing Za Zhi 2015;43(12):1018e21. [6] Inglis SC, Clark RA, Dierckx R, Prieto-Merino D, Cleland JG. Structured telephone support or non-invasive telemonitoring for patients with heart failure. Cochrane Database Syst Rev 2015;10:CD007228. [7] Heo S, Moser DK, Lennie TA, Fischer M, Smith E, Walsh MN. Modifiable correlates of physical symptoms and health-related quality of life in patients with heart failure: a cross-sectional study. Int J Nurs Stud 2014;51(11):1482e90. [8] Matsuoka S, Tsuchihashi-Makaya M, Kayane T, et al. Health literacy is independently associated with self-care behavior in patients with heart failure.
(2.54) (2.68) (2.39) (5.74)
(2.31) (2.57) (2.21) (5.82)
Test-retest reliability
0.87 0.79 0.90 0.91
Patient Educ Couns 2016;99(6):1026e32. [9] Vinson JM, Rich MW, Sperry JC, Shah AS, McNamara T. Early readmission of elderly patients with congestive heart failure. J Am Geriatrics Soc 1990;38(12):1290e5. [10] Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int 2000;15(3):259e67. [11] Ishikawa H, Takeuchi T, Yano E. Measuring functional, communicative, and critical health literacy among diabetic patients. Diabetes Care 2008;31(5): 874e9. [12] Kim MT, Song HJ, Han HR, et al. Development and validation of the high blood pressure-focused health literacy scale. Patient Educ Couns 2012;87(2): 165e70. [13] Echeverri M, Anderson D, Napoles AM. Cancer health literacy test-30-spanish (CHLT-30-DKspa), a New spanish-Language version of the Cancer health literacy test (CHLT-30) for spanish-speaking Latinos. J Health Commun 2016;21(Suppl):69e78. [14] Matsuoka S, Kato N, Kayane T, et al. Development and validation of a heart failure-specific health literacy scale. J Cardiovasc Nurs 2016;31(2):131e9. [15] Nielsen-Bohiman L, Panzer AM, Kindig DA. Health literacy: a prescription to end confusion. Washington, D.C.: The National Academies Press; 2004. p. 146e90. [16] Valmi DS, Wilaiporn R. Translation,adaptation and validation of instruments or scales for use in cross-culture health care research:a clear and user-friendly guidelin. J Eval Clin Pract 2011;17(2):268e74. [17] Brislin RW. Back-translation for corosscultural research. J Cross Cultural Psychol 1970;1:185e216. [18] Matsuoka S, Kato N, Kayane T, et al. Development and validation of a heart failure-specific health literacy scale. J Cardiovasc Nurs 2016;31(2):131e9. [19] Reilly CM, Higgins M, Smith A, et al. Development, psychometric testing, and revision of the Atlanta heart failure knowledge test. J Cardiovasc Nurs 2009;24(6):500e9. [20] Yehle KS, Sands LP, Rhynders PA, Newton GD. The effect of shared medical visits on knowledge and self-care in patients with heart failure: a pilot study. Heart Lung J Crit Care 2009;38(1):25e33. [21] Artinian NT, Magnan M, Sloan M, Lange MP. Self-care behaviors among patients with heart failure. Heart Lung J Crit Care 2002;31(3):161e72. [22] Kaiser H. An index of factorial simplicity. Psychometika 1974;39:31e6. [23] Fabrigar L, MacCallum R, Wegener D. Evaluating the use of exploratory factor analysis in psychological research 1999;4:272e90. [24] Wheaton B. Assessment of fit in overidentified models with latent variables. Sociol Methods Res 1987;6(1):118e54. [25] Bentler PM. Comparative fit indexes in structural models. Psychol Bull 1990;107(2):238e46. [26] Schermelleh-Engel K, Moosbrugger H, Müller H. Evaluating the fit of structural equation models: tests of significance and descriptive goodnessof-fit measures. Methods Psychol Res Online 2003;8(2):23e74. [27] Portney LG, Watkins MP. Foundation of clinical research: application to practice. 2nd ed. Upper Saddle River, NJ: Prentice Hall; 2000.
Please cite this article in press as: Yue M, et al., Translation and psychometric evaluation of the Chinese version of the Heart Failure-Specific Health Literacy Scale, International Journal of Nursing Sciences (2016), http://dx.doi.org/10.1016/j.ijnss.2016.11.004
Contents lists available at ScienceDirect
H O S T E D BY
International Journal of Nursing Sciences journal homepage: http://www.elsevier.com/journals/international-journal-ofnursing-sciences/2352-0132
ORIGINAL ARTICLE
Translation and psychometric evaluation of the Chinese version of the Heart Failure-Specific Health Literacy Scale Meng Yue a, Lijun Zhang b, Yuanyuan Lu c, Changde Jin a, * a
Nursing College, Tianjin University of Traditional Chinese Medicine, Tianjin, China Cardiology department, Tianjin People's Hospital Tianjin Union Medical Center, Tianjin, China c Cardiology department, Tianjin First Center Hospital, Tianjin, China b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 August 2016 Received in revised form 31 October 2016 Accepted 2 November 2016 Available online xxx
Objective: Health literacy is closely associated with self-care behaviors in heart-failure patient. A reliable, valid, and practical measuring tool would evaluated the level of health literacy in Chinese patients with heart failure, and provide evidence for individualized education. Aim of this study was to translate Heart Failure-Specific Health Literacy Scale (HF-Specific HL Scale) into Chinese and test the reliability and validity of the Chinese version. Methods: The original HF-specific HL scale was translated into Chinese and modified for cultural adaption. Totally 164 HF inpatients were investigated with the Chinese version of HF-specific HL scale. To test the reliability and validity of the scale, item analysis, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and correlation analysis were conducted. Result: Cronbach's a value for the scale is 0.87; the correlation coefficients between each item and the total score ranged from 0.61 to 0.91. Three factors was extracted by EFA, which could explain 64.62% of the total variance. The result of CFA also showed that the scale demonstrated an acceptable model fit. The scale was significantly correlated with the Chinese version of the Heart Failure Knowledge Test (C-HFKT). Conclusion: The Chinese version of HF-specific HL scale is reliable and valid, and is suitable for assessment of HL in Chinese HF patients. © 2016 Chinese Nursing Association. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Health literacy Heart failure Scale Psychometric evaluation
1. Introduction Heart failure (HF) is the end of the development prognosis for many cardiovascular disease. For HF patients, the activity endurance has been limited, and the quality of life became worse [1]. In developed countries, the morbidity of HF is more than 10% among population who are older than 65 years old and more than 5.7 million people experience HF in the US [2,3]. In developing countries, HF was characterized by high morbidity, high mortality, and long hospital stay [4]. It has been reported that four million people in China has been suffered from HF [5]. Patients experiencing HF not only must adhere to long-term and complex medication, but also must change their lifestyle. Improving the self-care behavior of HF patient is the effective way to prevent HF patients from frequently readmission, it helps
* Corresponding author. E-mail address: [email protected] (C. Jin). Peer review under responsibility of Chinese Nursing Association.
reduce the cost and improve their quality of life [6,7]. Acquiring and applying the related health care information is an important step to improve self-care behaviors for HF patients. With the development of network information technology, the approach individuals acquire information has not been limited to health care professionals or medical care personnel. More and more patients obtain information from Internet and relevant media. However, information patients seeking voluntarily may be false, people who trust and obey it would cause a tragedy. So the ability called health literacy (HL) including seek, understand, critically evaluate, and apply information becomes essential. Recent research suggested that HL was associated with self-care behaviors among HF patient [8]. As a consequence, heighten the level of HL contributes to the improvement of HF patients' self-care behaviors, decrease of hospitalization rate and readmission rate. Toward targeting public health efforts to improve self-care behaviors of HF patient, develop an instrument to measure their HL level is necessary [9]. Netbeam [10] proposed the HL concept based on his/her health promotion theory. The HL concept contains three sections: functional HL, interactive HL and critical HL. Functional HL refers to the
http://dx.doi.org/10.1016/j.ijnss.2016.11.004 2352-0132/© 2016 Chinese Nursing Association. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Yue M, et al., Translation and psychometric evaluation of the Chinese version of the Heart Failure-Specific Health Literacy Scale, International Journal of Nursing Sciences (2016), http://dx.doi.org/10.1016/j.ijnss.2016.11.004
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M. Yue et al. / International Journal of Nursing Sciences xxx (2016) 1e5
basic reading and writing skills. Interactive HL is an advanced skill compared to functional literacy which refers to extracting and understanding information in daily-life situations. Critical HL refers to the ability to analyze and utilize information, it represents the dominate of the disease state. Upon Netbeam's HL concept, specific HL scales focus on chronic disease such as diabetes, high blood pressure, and cancer have been developed [11e13]. To assess the HL level of HF patients, Shiho Matsuoka [14] developed the HF-specific HL scale, which comprises three dimensions and 12 items. This scale use four scoring options as following: 1 ¼ inapplicable; 2 ¼ rarely applicable; 3 ¼ sometimes applicable; and 4 ¼ strongly applicable. High scores correlated with high level of HL. Shiho Matsuoka applied the scale in outpatients, and the result confirmed that the reliability and validity of the scale were adequate. The specific scales focusing on certain disease or state could immediately and correctly reflect the condition and requirement of patients [15]. By translation, back-translation, and cultural adaptation the Chinese version HF-specific HL Scale and apply the scale, the aim of the study was to establish a Chinese version HF-specific HL Scale which is appropriate for HF patients in Mainland China, so as to provide scientific instrument to measure patients' HL level and take corresponding measures to improve HL levels on the basis of the results. 2. Methods 2.1. Study design and setting The study consisted of two phases. The first phase aimed to translate and revise the HF-specific HL Scale; the second phase was to test the reliability and validity of the Chinese version. The study was carried out in two hospitals in Tianjin. The inclusion criteria was as follows: diagnosis of HF; aged 18 years or above; NYHA (New York Heart Association Functional Classification) class III~IV. Patients who meet the following criteria were excluded: had physical disease or cognitive impairment (the score of Mini-Mental State Examination was lower than 2). In this study, the sample size was 10 times of the items number [16], then added 20% invalid questionnaires, thus the total sample size was 164. The researcher communicated with the respondents and explained the purpose, significance, and process of the survey. The patients were entitled to participate or withdraw the survey. Patients agreed to participate in the survey were enrolled. 2.2. Forward-translation, back-translation, and cultural adaptation of HF-specific HL scale After authorized by Shiho Matsuoka, we translated and revised the scale according to the procedure proposed by Brislin [17]. The scale was forward-translated and back-translated as follows. Firstly, two bilingual researchers including a clinic nurse major in HF care who has a master degree and one doctor who graduated from the UK translated the English version into Chinese version. Then, the result was recorded by another researcher and checked by a HF care expert; Thirdly, two other clinic nurses major in HF care who have master degree and didn't know the scale before back translated the scale. Cultural adaptation was performed by 8 experts, including two cardiac physicians, three clinic nurses major in HF care, and three health care experts. The experts were invited to revise the items which were not suited to the culture in Mainland China. After final version was confirmed, 8 experts rated the content validity with a 4-point Likert scale: 1 ¼ not relevant; 2 ¼ somewhat relevant; 3 ¼ quite relevant; 4 ¼ very relevant. Ten HF patients satisfied the inclusion criteria mentioned above
participated in a pilot study. Their intelligibility towards the items and completion time was obtained. 2.3. Instruments The day before hospital discharge, patients were asked to complete the questionnaires including HF-specific HL Scale and CHFKT. The clinical data was collected by the researcher according to the medical record. Instruction for filling in the questionnaires was introduced by one researcher. After retrieving the questionnaires, the researcher checked them in case some items were omitted. 2.3.1. Demographic and clinical data Demographic data included age, gender, education level, employment status, and income per month. Clinical data included etiology, NYHA classification and complication. 2.3.2. Chinese version of HF-specific HL scale HF-specific HL Scale is a self-report scale. The scale with 3 dimensions and 12 items. The score of each item ranges from 1 to 4. The total score of the scale is 36. 2.3.3. Chinese version of Heart Failure Knowledge Test (C-HFKT) The questionnaire investigates the knowledge about the case and symptom of HF, the adherence of low salt diet, the effect and side effect of their medicine, and lifestyle that should persist by HF patients [18]. The questionnaire consists of 12 choice questions and 1 fill-in-the-blank question. The score of each item is 1, and the total point of the test is 13. A high score indicates exact HF knowledge. Currently, this questionnaire has been broadly accepted in research [19e21]. 2.4. Data analysis Data was analysis with the Statistical Package for Social Science (SPSS) version 17.0 for windows and AMOS 18.0. Descriptive analysis was used for evaluate the demographic and clinical data. Psychometric properties of Chinese HF-specific HL Scale were reflected by validity and reliability. 2.4.1. Validity CVI was measured to evaluate the content validity of the HFspecific HL Scale. The construct validity of HF-specific HL Scale was assessed using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Kaiser Meyer Olkin Measure (KMO) of Sampling Adequacy and Bartlett's Test of Sphericity were calculated prior to performing EFA which would explore the dimensions in the scale. If the KMO was found to be greater than 0.6 [22] and the Bartlett's Test of Sphericity was significant, the data is suitable for principal components analysis [23]. We perform principal components analysis with oblique rotation for factor rotation to explore the factorial structure. The three-factor model for the HF-specific HL scale was tested through a CFA Model. The quality of fitness was assessed by Chi Square (c2/df), Comparative Fit Index (CFI), Goodness of Fit Index (GFI), Adjusted Goodness of Fit Index (AGFI), Normed Fit Index (NFI), and Root Mean Square Error of Approximation (RMSEA). If c2/df was less than 5.0 [24], CFI, GFI, AGFI, and NFI was higher than 0.9 [25], and RMSEA was lower than 0.08 [26], the model was considered to have acceptable fit. Criterion-related validity was examined by evaluating the correlation coefficient (Person relation analysis) between the scores of HF-specific HL Scale and C-HFKT. 2.4.2. Reliability The internal consistency was assessed by calculating the
Please cite this article in press as: Yue M, et al., Translation and psychometric evaluation of the Chinese version of the Heart Failure-Specific Health Literacy Scale, International Journal of Nursing Sciences (2016), http://dx.doi.org/10.1016/j.ijnss.2016.11.004
M. Yue et al. / International Journal of Nursing Sciences xxx (2016) 1e5
Cronbach's a values and the split-half reliability. The Cronbach's a value of the whole scale and three dimensions were measured. The split-half reliability was conducted by dividing the items into two sections according to the odevity of item numbers, and calculated the correlation coefficient of the two halves. Test-retest reliability were also assessed. 30 participants were randomly selected from the 164 participants, and they were reevaluated 4 weeks later when they came for a check-back. Data were analysed by Pearson relation analysis for testeretest reliability. The test-retest reliability was acceptable when the correlation coefficient was higher than 0.75 [27].
3
from hospitals”, because in Chinese Mainland, pharmacies only offer drugs and they do not have the right to prescribe. During the adaption, six experts insisted that item 8 and item 9 were supposed to be exchanged, because according to Netbeam's HL concept, item 8 belongs to critical HL, and item 9 belongs to interactive HL. To verify this hypothesis, the validity and reliability after exchanging the two items were calculated. In the pilot study, all patients could understand every item, their judgment towards the meaning of the scale accorded with the established purpose. It took about 3 minutes to complete the scale. 3.2. Psychometric properties of HF-specific HL scale
3. Results 3.1. Translation and cultural adaptation of the HF-specific HL scale The back-translated version was contrasted with the original version, the researcher realized that the term “shortness of breath” was back-translated into “dyspnea”, to our knowledge, the former was an informal expression and the latter was a specialized vocabulary. Considering that “dyspnea” denote a broader concept, this term was retained. When communicated with the patients, the researcher used “shortness of breath” and “labored breathing”, which realized the semantic equivalence. To adapting the medical environment in Chinese Mainland, the experts suggested that the statement “The prescriptions and pamphlets from hospitals and pharmacies” in item 1, item 2, and item 3 should be replaced by “The prescriptions and pamphlets Table 1 dThe result of KMO and Bartlett's Test the HF-specific HL scale (Chinese version). Item
Score
KMO of sampling adequacy Bartlett's test of sphericity
0.820 9642.164 503 0.000
Approx. Chi-Square df Sig.
3.2.1. Demographic and clinical data 164 inpatients treated at cardiology department were surveyed. The mean age of the patients was 58.02 (SD 15.25), the proportion of patients older than 60 was 52.4%. The majority of patients were males, 31.1% patients had received senior high school education. 54.2% patients were in NYHA class III and 45.8% were in NYHA IV. Among them, the common etiology was coronary heart disease, myocardiopathy, valvular disease, and pulmonary heart disease. 72.5% patients had one complication or less. 3.2.2. Validity Based on scores from experts, the sale-level CVI (S-CVI) was gotten by calculating the ratio of item number which scored 3 or 4 to item amount; divided the number of experts who scored 3 or 4 by total expert number, the item-level CVI (I-SVI) of each item was assessed. The result showed that the S-CVI was 0.879, and the I-SVI was in the range of 0.834e1.0. The KMO measure was 0.82, and Bartlett's Test of Sphericity was acceptable (P < 0.05) (Table 1), the result supported the suitability for EFA. The scree plot indicated 3 factors were extracted (Fig. 1), which accounted for 64.62% of the total variance, with the loading of variables on factors bigger than 0.79 (Table 2). The six fit indices for the CFA supported the three factor structure of HF-specific HL scale. Five out of six fit indices indicated acceptable fit, and the
Fig. 1. A scree plot illustrating the factor loading of the Chinese version of HF-specific HL scale.
Please cite this article in press as: Yue M, et al., Translation and psychometric evaluation of the Chinese version of the Heart Failure-Specific Health Literacy Scale, International Journal of Nursing Sciences (2016), http://dx.doi.org/10.1016/j.ijnss.2016.11.004
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M. Yue et al. / International Journal of Nursing Sciences xxx (2016) 1e5
Table 2 Factor loadings for the HF-specific HL scale (Chinese version). Item
Mean (SD)
1. 2. 3. 4. 5.
The prescriptions and pamphlets from hospitals are hard to read. There are terms that I do not understand in the prescriptions and pamphlets from hospitals. The content in the prescriptions and pamphlets from hospitals is hard to understand. It is difficult to write in handbooks and documents from hospitals and pharmacies. I have been able to have satisfactory conversations regarding heart failure with those close to me, including medical professionals. 6. I have been able to understand information regarding the treatment and symptoms of heart failure and everyday precautions. 7. I have notices changes in the symptoms of heart failure such as dyspnea, palpitations, and edema. 8. I have gathered knowledge on heart failure from television,radio, and Internet. 9. I have wondered whether the information regarding heart failure and its treatment is applicable to me. 10. I have had doubts regarding the credibility of information regarding heart failure and its treatment. 11. I have asked and checked whether information regarding heart and its treatment is accurate. 12. I have gathered information on hospitals and treatments to make my own decisions. Rotation sums of squared loading (Cumulative 100%)
Factor loading 1
2
3
2.97(0.87) 2.35(0.72) 2.69(0.88) 3.04(0.90) 2.91(0.79)
0.752 0.728 0.713 0.687 0.321
0.230 0.145 0.148 0.233 0.675
0.132 0.178 0.212 0.089 0.118
3.43(0.91)
0.201
0.622
0.276
3.25(0.83) 3.12(0.96) 3.04(0.89) 2.76(1.00) 2.48(0.79) 2.32(0.72)
0.239 0.127 0.217 0.364 0.103 0.228 54.578
0.605 0.553 0.411 0.112 0.147 0.216 62.575
0.281 0.405 0.546 0.687 0.741 0.643 76.499
The maximum factor loading of each item is presented with bold value.
remaining one were slightly below 0.90 (AGFI) (Table 3). Standardized parameter estimate for the structural equation modeling is showed in figure (Fig. 2). Pearson correlation between HF-specific HL scale and C-HFKT scores was 0.774 (P < 0.01). 3.2.3. Reliability As shown in Table 5, Cronbach's a value for the overall scale was 0.87, and Cronbach's a value for the 3 dimensions were 0.84, 0.72, and 0.69 respectively, indicating acceptable internal consistency. The Cronbach's a coefficient between each dimension and the scale ranged from 0.61 to 0.91 (Table 4). The split-half reliability of HFspecific HL Scale was 0.80, and the test-retest reliability was 0.79e0.94 (Table 5). 4. Discussion The present study demonstrated the application of HF-specific HL scale with good reliability and validity. The reliability of Chinese version HF-specific HL scale was higher than the original version, the reason may be that we exchanged the items 8 and item 9, which might fit the concept better, in addition, compared to the study before [14], we included patients who were in NYHA IV, so the condition of patients included in this study was more serious. Three components were extracted after EFA; which was consist with the original scale and Netbeam's HL concept [10]. Considering that there was not much difference between item 8 and item 9, further study was needed to confirm the adjustment. This study use C-HFKT scores as the criterion-related variable, which measure whether HF patients grasp relevant knowledge about HF [18]. The self-care behaviors in C-HFKT scores was embodied by HF-specific HL Scale. Positive statistically significant correlation were found between HF-specific HL Scale and C-HFKT scores which explain a good Criterion-related validity. Some limitations should be acknowledged in this study. The subjects enrolled in this study were inpatients, to explore the applicability of the Chinese version HF-specific HL Scale, outpatients and domiciliary HF patients should also be investigated in
Table 3 Result of confirmatory factor analysis for the three-factor model. Fit index
c
df
c /df
CFI
GFI
AGFI
NFI
RMSEA
Value
107.46
90.30
1.19
0.995
0.933
0.897
0.961
0.024
2
2
Fig. 2. Path diagram for the three-factor model with standardized parameter estimate.
the future study. Discriminant validity was not conducted in this study, and in order to improve the revision, qualitative research should be performed with the quantitative study.
5. Conclusion The Chinese version of HF-specific HL Scale, being reliable, valid and easy to use, is suitable to be adapted by clinical setting as a screening tool to recognize HF patients with low level of HL.
Table 4 Internal correlation matrix and the coefficient analysis between the scale and three dimensions.
Fictional literacy Interactive literacy Critical literacy HF-specific HL scale
Fictional HL
Interactive HL
Critical HL
1 0.45** 0.36* 0.72*
1 0.42* 0.61*
1 0.91**
**P < 0.01, *P < 0.05.
Please cite this article in press as: Yue M, et al., Translation and psychometric evaluation of the Chinese version of the Heart Failure-Specific Health Literacy Scale, International Journal of Nursing Sciences (2016), http://dx.doi.org/10.1016/j.ijnss.2016.11.004
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Table 5 Reliability test of the HF-specific HL scale and each dimension. Item
Fictional HL Interactive HL Critical HL HF-specific HL scale
Cronbach's a value
0.84 0.72 0.69 0.87
Test
Retest
Mean (SD)
Mean (SD)
12.03 12.26 10.97 35.26
12.08 12.20 10.93 35.21
Author contributions Yue and Jin conceived the study. Zhang and Lu collected the data. Yue and Jin analyses the data. Yue draft the manuscript. Conflicts of interest None declared. Acknowledgments The authors would like to thank Shiho Matsuoka, who offer the English version of HF-specific HL scale. The authors also thank the medical staff in Tianjin People's Hospital, Tianjin Union Medical Center, and Tianjin First Center Hospital. References [1] Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American college of cardiology foundation/American heart association task force on practice guidelines. Circulation 2013;128(16):1810e52. [2] Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics2016 update: a report from the American heart association. Circulation 2016;133(4):e38e60. [3] Ponikowski P, Voors AA, Anker SD, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2016;18(8):891e975. [4] Magana-Serrano JA, Almahmeed W, Gomez E, et al. Prevalence of heart failure with preserved ejection fraction in Latin American, middle Eastern, and North African regions in the I PREFER study (identification of patients with heart failure and PREserved systolic function: an epidemiological regional study). Am J Cardiol 2011;108(9):1289e96. [5] Zhou J, Cui X, Ge J. The epidemiological profile of heart failure patients in China. Zhonghua Xin Xue Guan Bing Za Zhi 2015;43(12):1018e21. [6] Inglis SC, Clark RA, Dierckx R, Prieto-Merino D, Cleland JG. Structured telephone support or non-invasive telemonitoring for patients with heart failure. Cochrane Database Syst Rev 2015;10:CD007228. [7] Heo S, Moser DK, Lennie TA, Fischer M, Smith E, Walsh MN. Modifiable correlates of physical symptoms and health-related quality of life in patients with heart failure: a cross-sectional study. Int J Nurs Stud 2014;51(11):1482e90. [8] Matsuoka S, Tsuchihashi-Makaya M, Kayane T, et al. Health literacy is independently associated with self-care behavior in patients with heart failure.
(2.54) (2.68) (2.39) (5.74)
(2.31) (2.57) (2.21) (5.82)
Test-retest reliability
0.87 0.79 0.90 0.91
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Please cite this article in press as: Yue M, et al., Translation and psychometric evaluation of the Chinese version of the Heart Failure-Specific Health Literacy Scale, International Journal of Nursing Sciences (2016), http://dx.doi.org/10.1016/j.ijnss.2016.11.004