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Geriatric Nursing
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A R T I C L E I N F O A B S T R A C T
Article history: Caring for people with dementia causes heavy care burdens to their families. Family coping is important in
Received 19 January 2022 decreasing burdens and promoting family adaptation. To comprehensively assess and understand these
Received in revised form 17 March 2022 issues, we validated the Chinese version of the Family Crisis Oriented Personal Evaluation Scales (F-COPES)
Accepted 18 March 2022
which is widely used to evaluate family coping. Data for psychometric property evaluation were obtained
Available online xxx
from 215 family members of patients with dementia. The instrument showed satisfactory content validity
(scale content validity index 0.98), convergent validity (r = 0.50, P < 0.01), and internal consistency (Cron-
Keywords: bach’s alpha 0.86). The confirmatory factor analysis identified six factors, namely, acquiring relatives’ sup-
Family coping port, acquiring friends’ support, acquiring neighbors’ or others’ support, seeking spiritual support, reframing,
Validity and passive appraisal (x2/df 1.86, CFI 0.88, TLI 0.87, PGFI 0.68, RMSEA 0.06). This instrument may serve as a
Reliability useful scale for assessing the coping behaviors of families of patients with dementia in mainland China.
Chinese
© 2022 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
Dementia
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
https://doi.org/10.1016/j.gerinurse.2022.03.008
0197-4572/$ see front matter © 2022 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
132 Q. Wang et al. / Geriatric Nursing 45 (2022) 131139
Malay version, and Turkish version, etc.13-15 Two small studies of Chi-
nese-American and Hong Kong Chinese established Chinese versions of
the F-COPES among breast cancer survivors and critically ill patients,
respectively.16,17 However, those Chinese versions lack comprehensive
evidence of its psychometric properties and cannot be directly used in
mainland Chinese populations, due to the distinct social and cultural
environments in China.18 To the best of our knowledge, to date, there
are no Chinese versions of this scale developed and validated in main-
land China. Thus, in the present study, we developed a Chinese version
of the F-COPES using the standard procedure of translation and cultural
adaptation, and evaluated its psychometric properties in families of
patients with dementia in mainland China. The present study hypothe-
sizes that the Chinese version of F-COPES demonstrates similar accept-
able content validity, convergent validity and internal consistency with
the original F-COPES, and the factor structure may differ from the origi-
nal F-COPES due to cultural differences.
Methods
judge whether each item of the initial Chinese version of F-COPES Factor structure
should be deleted or modified and whether we should add other In the confirmatory factor analysis in the current study, the origi-
items. nal model established based on the factor structure of the English
In the adaptation process, we deleted the items of Nos. 9, 29, and version of the F-COPES was tested first. We then established a new
30 from the Chinese version of the F-COPES after obtaining permis- six-factor competing model based on parts of the original model and
sion from the author. Item 9 (“Seeking information and advice from the classification of social support.33 In the competing model, we
the family doctor”) was deleted because the system of family doctors, made no changes in the following three out of five subscales in the
which is commonly understood internationally, does not exist in original model: seeking spiritual support, reframing, and passive
China.25 Item 29 (“Sharing problems with neighbors”) was deleted appraisal. For the other two subscales which consist of 12 items
because families of patients with dementia are reluctant to share totally in the original model (i.e., mobilizing the family to acquire and
problems with neighbors when facing the discrimination and preju- accept help, and acquiring social support), we rearranged them into
dice against patients with dementia and their families in China.26,27 three new subscales based on the source of social support: namely,
Item 30 (“Having faith in God”) was deleted because only 10.4% of acquiring relatives’ support, acquiring friends’ support, and acquiring
Chinese participants identified themselves as religious.28 Only 6.5% of neighbors’ and others’ support. We made this rearrangement in the
family members in the current study had religious faith, although competing model because in the original model the 12 items in the
they participate in religious practices. We modified the items (items subscales of mobilizing the family to acquire and accept help, and
of Nos. 14, 23, 27) that described religious practices as coping meth- acquiring social support are recognized as coping behaviors of acquir-
ods in the subscale of seeking spiritual support. We broadened the ing social support. The subscale of acquiring social support in the
Christian terms in these items to comprehensively suit other reli- original model only covers the acquirement of community resources.
gions, which was similar to the Turkish version of the F-COPES15 The items of acquiring support from relatives, friends, and neighbors
since the Chinese participants were engaged in some form of reli- were included in the subscale of mobilizing the family to acquire and
gious practice across the various religions.28 Finally, all experts accept help. So, we combined these two subscales firstly. Our choice
agreed there was no need to add any new items. of rearranging them into three subscales was based on the fact that
in China the extent to which people acquire and accept help or social
support generally varies by the intimacy of the relationship, with
Multidimensional Scale of Perceived Social Support (MSPSS) most help or social support acquired from relatives, followed by
The MSPSS was selected to evaluate the convergent validity of F- friends, neighbors and other.34 This is also in line with the initial
COPES in this study. The MSPSS measured the perceived social sup- English version of F-COPES developed by McCubbin et al35 in 1991,
port from three informal sources: family, friends, and significant which arranged those 12 items in subscales according to the source
others. Participants were rated on a seven-point Likert response for- of social support. The competing model was then tested by using con-
mat (1 = “very strongly disagree” to 7 = “very strongly agree”). The firmatory factor analysis.
total score is summed by the scores of items, with higher scores We further modified both the original and competing models
indicative of greater perceived social support. Zimet et al.29 tested according to the guideline for model modification using structural
the MSPSS and reported high internal consistency of 0.88. The test- equation modeling.36 As recommended by that guideline36, we per-
retest reliability was 0.85 over a 2- to 3-months period after complet- formed the model modification in the following two ways: 1) adding
ing the questionnaire.29 The MSPSS had a Cronbach’s alpha coeffi- correlations between items to the error term in the equation if two
cient of 0.90 in the current study. items were recognized as having similar meaning and the modifica-
tion indices between them in the structural equation modeling 4;
Statistical analysis 2) deleting correlations between subscales when their correlation did
not reach statistical significance (P > 0.05). And all the modifications
After translation and adaptation of the F-COPES, we performed a in this research were based on hypotheses in the relevant field.
content validity analysis, item homogeneity analysis, factor structure The data fitness of the modified original model and modified com-
analysis, convergent validity analysis, and internal consistency reli- peting models of F-COPES were compared. The factor structure of the
ability of the F-COPES. We used IBM SPSS Amos Version 20.0 (IBM; F-COPES was analyzed by confirmatory factor analysis. The criteria
Armonk, NY, USA) for factor structure analysis and IBM SPSS Statistics used to determine whether the models of factor structure fit the data
Version 17.0 (IBM; Armonk, NY, USA) for other analyses. were 3.00 or lower on the chi-square of model fit/degree of freedom
(x2/df),37 0.90 or greater on the comparative goodness-of-fit index
Content validity (CFI), and the Tucker-Lewis Index (TLI); 0.50 or greater on parsimony
Content validity analysis was explored by the item content valid- goodness-of-fit index (PGFI)38-41; and 0.08 or lower on a root-mean-
ity index (I-CVI) and the scale content validity index (S-CVI). Six square error of approximation (RMSEA).42 If the value of CFI of the
experts were invited to quantify the relevance of items to family cop- modified competing model is at least 0.01 higher than the modified
ing by using a rating scale (not relevant or somewhat relevant = 0, original model, the modified competing model is then considered sig-
quite relevant, and very relevant = 1). The I-CVI is the average of all nificantly better than the modified original one.43
experts rating the results of each item, and S-CVI is the average of I-
CVIs. The I-CVI is recommended to be no lower than 0.78 and an S- Convergent validity
CVI of 0.80 or higher is acceptable.30,31 Convergent validity of the F-COPES was tested by estimating its
correlation with social supports as measured by the MSPSS since
social support has been shown be to be correlated to caregiver cop-
Item homogeneity analysis ing.44 The correlation coefficient for convergent validity between
Item homogeneity analysis was tested using a corrected item-sub- 0.10 and 0.29 was considered weak, 0.30 to 0.49 was considered
scale correlation, item-total correlation, and Cronbach’s alpha coeffi- moderate, and 0.50 to 1.0 was considered strong.45
cient of the subscale after deleting each item. The corresponding
item is acceptable if the corrected item-subscale correlation is higher Internal consistency reliability
than 0.20, and the value of Cronbach’s alpha coefficient of the scale The internal consistency reliability of the scale and subscales were
after deleting each item is lower than before the deletion.32 evaluated by Cronbach’s alpha coefficients. A Cronbach’s alpha
134 Q. Wang et al. / Geriatric Nursing 45 (2022) 131139
coefficient between 0.80 and 0.90 was considered perfect, and 0.65 Table 1
was the lowest acceptable cut point.46 Characteristics of patients and families (N=215)
Table 2
Item homogeneity of each item and the whole scale of the original version of the F-COPES (N=215)
No. Items Corrected item-total Corrected item-subscale Cronbach's alpha coefficient of the
correlation correlation subscale/Cronbach's alpha
coefficient of the subscale after
deleting each item a
convergent validity, and internal consistency reliability of the whole were representative internationally.13,15 This could owe to the inte-
scale. We also established the six-factor structure of the F-COPES, which grated and systematic theoretical framework of the F-COPES based
is different from other language versions. The F-COPES may serve as a on the Resiliency Model developed and validated by McCubbin and
useful scale for assessing the coping behaviors in families of patients his colleagues.6
with dementia in China. The present study is one of few to develop and
validate a Chinese version of the F-COPES in mainland China. Item homogeneity
Content validity We found that the items in the subscales for acquiring social sup-
port, mobilizing the family to acquire and accept help, seeking spiri-
The Chinese version of the F-COPES satisfactorily covered relevant tual support, and reframing were homogeneous, as indicated by the
domains of family coping, because the relevance of the items (i.e., results of the corrected item-subscale correlation and Cronbach's
content validity indexes of the whole scale and items) was perfect. alpha coefficient of the subscale after deleting each item. These find-
The entire expert panel agreed that the included items in the Chinese ings were similar to those from other studies in different
version adequately represented the content or behaviors in the countries.13,14
domain of family coping. Our findings are in line with those from sev- Of note, the homogeneity of items in the subscales of passive
eral studies of different language versions (i.e., the Persian version appraisal was unsatisfactory because of the inappropriate original
and Turkish version) which reported that the items in the F-COPES scoring of items 12 and 28 in the Chinese version. In the present
136 Q. Wang et al. / Geriatric Nursing 45 (2022) 131139
study, the homogeneity of items in the passive appraisal subscale was The Chinese version of F-COPES had perfect internal consistency
improved after reversing into positive scoring for item 12—“watching as the Cronbach’s alpha coefficient of this measure was 0.86. The
TV”—and item 28—“believing if we wait long enough, the problem internal consistency reliability of the subscales were good as well,
will go away.” Item 12 in our Chinese version of the F-COPES should except for the passive appraisal subscale. This finding was similar to
be positively scored because watching TV has proven to be a very that in another study.16 There are two possible explanations for this
helpful coping behavior when dealing with high levels of stress.47,48 result. First, this result could be due to the population we measured.
We also positively scored item 28, which could be partly supported The passive appraisal is always the least used coping method among
by the notion that “believing if we wait long enough, the problem the families of patients with dementia.53 In the current study, more
will go away” may play a beneficial role in coping mechanisms for than half of the family members only used one or two of these four
Chinese families when facing difficulties, because Chinese culture val- coping methods, thereby influencing the internal consistency. Sec-
ues the virtues of patience, waiting, and forbearance.16 ondly, it might be associated with the fact that there were only four
items in this subscale.54 Taken together, our findings suggested we
should add more items in this subscale focusing on the family mem-
Factor structure bers of patients with dementia to improve its internal consistency
reliability by increased applicability and appropriate item redun-
The subcomponents of the family coping that the Chinese version dancy.
of the F-COPES identifies in families of patients with dementia
included acquiring relatives’ support, acquiring friends’ support, Strength and limitations
acquiring neighbors’ or others’ support, seeking spiritual support,
reframing, and passive appraisal (Fig. 2). This six-factor model of the The major strength of this study was that we developed the Chi-
Chinese version of F-COPES fit better the observed data as the results nese version of F-COPES and evaluated its psychometrics in families
show in Table 3. This model was partly different from other language of patients with dementia, including content validity, item homoge-
versions, such as the three-factor Turkish version15 and the five-fac- neity, factor structure, convergent validity, and internal consistency
tor African American versions.49 In the Chinese version, the 12 items reliability of the F-COPES. Our research also has limitations. First,
in the original subscale of mobilizing the family to acquire and accept some items should be added, especially in the subscale of passive
help and the original subscale of acquiring social support were appraisal. Second, we urge caution in generalizing our findings to
divided into three new subscales depending on the source of the other populations since the study population was restricted to fami-
social support. It supported the suggestion of a previous study, which lies of patients with dementia; future studies among other popula-
encourages dividing the coping skills of “acquiring social support” tions are warranted to confirm our findings.
depending on the source of the social support in the Chinese popula-
tion because of its familism culture and the fact that in China the Conclusion
extent to which people acquire and accept help or social support gen-
erally varies by the intimacy of the relationship.16,34,50,51 This study demonstrated that the Chinese version of the F-COPES
Besides that, in the Chinese version of F-COPES, the correlations showed satisfactory psychometric properties. Our findings suggest
between the subscale of seeking spiritual support and the three sub- that it may serve as a useful scale for assessing the coping behaviors
scales—acquiring relatives’ support, reframing, and passive in families of patients with dementia from the perspective of the fam-
appraisal—disappeared. There were not the same as results of other ily systems in mainland China.
Q. Wang et al. / Geriatric Nursing 45 (2022) 131139 137
Fig. 2. Factor structure of the Chinese version of the Family Crisis Oriented Personal Evaluation Scales (F-COPES). The factor structure of the Chinese version of the F-COPES was
identified based on the modified competing model of the F-COPES, including the six factors—acquiring relatives’ support, acquiring friends’ support, acquiring neighbors’ or others’
support, seeking spiritual support, reframing, and passive appraisal—and the correlations between them. In the modified competing model, we combined three items in the original
subscale regarding mobilizing the family to acquire and accept help, and nine items in the original subscale of acquiring social support. Then, these 12 items were divided into three
new subscales depending on the source of the social support, including the subscale of acquiring relatives’ support, the subscale of acquiring friends’ support, and the subscale of
acquiring neighbors’ or others’ support. We deleted the correlations between the subscale for seeking spiritual support along with three other subscales—acquiring relatives’ sup-
port, reframing, and passive appraisal—because the correlations between them were not significant (P>0.05). The fitness of the modified competing model was analyzed and the
results showed that the comparative goodness-of-fit index of the modified competing model was 0.05 higher than that of the modified original model, which means the modified
competing model was significantly better than the modified original model. In this figure, we show the six factors of the modified competing model, the correlations between the
factors, the factor-loading from the six factors of the F-COPES to each item, the square of the factor loading of each item (at the top-right corner of each item) and the correlations
between the errors of items based on standardized estimates.
138 Q. Wang et al. / Geriatric Nursing 45 (2022) 131139
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Acknowledgment
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