Geriatric Nursing 45 (2022) 131
139

Contents lists available at ScienceDirect

Geriatric Nursing
journal homepage: www.gnjournal.com

Validation of the Chinese version of the Family Crisis Oriented Personal

Evaluation Scales in families of patients with dementia
Qingyan Wang, PhDa, Sanmei Chen, PhDb, Weiwei Liu, PhDc, Chang Zana, Yu Sheng, PhDd,*
a
Department of Clinical Nursing, School of Nursing, Xuzhou Medical University, Xuzhou Medical University Affiliated Oriental People's Hospital, Xuzhou, 221004,
China
b
Department of Global Health Nursing, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, 734-8551, Japan
c
School of Nursing, Army Medical University, Chongqing, 400038, China
d
School of Nursing, Peking Union Medical College, Beijing, 100144, China

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/)

Introduction adaptation.7 A tool to identify the number and category of coping

efforts of families of patients with dementia is necessary to identify
The number of people living with dementia worldwide is currently vulnerable families with insufficient coping efforts and the specific cat-
estimated at 55 million and will almost triple by 2050.1 The majority egories which they lack, which helps to develop interventions to
(80%) of people with dementia are receiving care in their homes by enhance the coping behaviors or attitudes of these families.
their families,2 included the spouses, children, children-in-law, and There are some instruments available for evaluating the coping skills
grandchildren who were living together with the patients or taking from the family systems perspective, such as Family Coping Question-
care of the patients on a routine basis.3 People with moderate to severe naire (FCQ),8 Family Coping Behavior Inventory,9 Family Coping Inven-
dementia can no longer live independently,1 which causes heavy stress tory (FCI),6 and Dyadic Coping Inventory (DCI).10 But most of them were
and care burdens to their families.4 The heavy stress and care burdens developed and used for a very small range of families or parents of med-
lead their families to have impaired physical and psychological health, ical fragile children.8,9,11,12 The Family Crisis Oriented Personal Evalua-
and further influence the caregiving quality.5 Coping of families refers tion Scales (F-COPES) was the most commonly used instrument to
to specific efforts that an individual family member or the family func- measure family coping efforts via self-reporting of family members of
tioning as a whole makes to reduce the stress and burden, such as medically fragile adults.13 McCubbin and his colleagues developed and
behaviors of managing the demand on the family system or attitudes validated the original English version of this scale based on their Resil-
of redefining stresses.6 The number and categories of family coping iency Model, which integrated both internal and external factors influ-
efforts are important in decreasing stress and promoting family encing the coping efforts of a family (i.e., family resources, social
support, and attitudes).6 The original English version included 30 items
Abbreviations: F-COPES, Family Crisis Oriented Personal Evaluation Scales; MSPSS, and five subscales, including the subscale of acquiring social support,
Multidimensional Scale of Perceived Social Support; x2/df, chi-square of model fit/df; the subscale of reframing, the subscale of seeking spiritual support, the
CFI, comparative goodness-of-fit index; TLI, Tucker-Lewis Index; PGFI, parsimony subscale of mobilizing the family to acquire and accept help, and the
goodness-of-fit index; RMSEA, root mean square error of approximation; IQR, inter-
quartile range; I-CVI, item content validity index; S-CVI, scale content validity index
subscale of passive appraisal.6 The original English version has been
*Corresponding author. translated into different languages, resulting in the Persian version,
E-mail address: [email protected] (Y. Sheng).

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) 131
139

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

Design and setting

A cross-sectional study was conducted in the specialist memory

and geriatric psychiatric clinics of four hospitals in Beijing of China
from October 2017 to March 2018.

Participants and recruitment

Participants were recruited using convenience sampling. Family

members were considered eligible for this study if their relatives
with dementia were aged  60 years and taken care of at home for at Fig. 1. Assembly of the study sample
least six months. According to the equations of the minimum sample
d
size (Ne ¼ e1
b2 df þ 1), the minimum sample size of our study was 108, whether they have religious faith (yes or no), and family income per
when the df = 218, e = 0.05, the power (1-b) = 0.80, and the month per person.
d1
b = 58.182 (d is the non-centrality parameter).19 We initially
recruited 250 patients who were diagnosed with dementia at least Family Crisis Oriented Personal Evaluation Scales (F-COPES)
six months prior. Through the physician's referral, we invited one The F-COPES was the most commonly used instrument to measure
family member of each patient, who were the primary caregivers of family coping via self-report. It was comprised of 30 items and five
each patient to fulfill our scales on behalf of the family. In total, 250 subscales.6 The five subscales included the subscale of acquiring social
family members were invited to participate in our survey. Of those, support (the family’s behaviors of actively engaging in acquiring sup-
25 refused to participate in this study because they had no interest or port from extended family, friends, and neighbors), the subscale of
no time to answer the questions. Thus, a total of 225 family members mobilizing the family to acquire and accept help (the family’s behav-
agreed to participate in this study and provided written informed iors of seeking out and using community resources to cope with prob-
consent. For this analysis, we excluded 10 participants who had data lems), the subscale of seeking spiritual support (the family’s behaviors
missing for more than 10% of the survey. Therefore, the final sample or attitudes of acquiring spiritual support), the subscale of reframing
included 215 participants (Fig. 1). The Ethical Review Committee (the family’s behaviors or attitudes of redefining stresses/situations to
approved the study protocol on April 15, 2016 (Approval no. [2015] make them more manageable), and the subscale of passive appraisal
03) and the study was conducted in accordance with the principles of (passive/inactive coping behaviors or attitudes in managing problems).
the Declaration of Helsinki. All of the participants were informed Respondents were asked to choose the frequency of using different
about the aim and significance of this study, their right to quit at any coping methods on a scale of 1 (almost never) to 5 (almost always).
time, and how to fill in the scales. All participants provided written Items of Nos. 12, 17, 26, and 28 should be reverse scored when obtain-
informed consent. ing the total score of the F-COPES by summing the responses of all
items. This is because the coping behaviors or attitudes described in
Measurements the items of Nos. 12, 17, 26, and 28 were considered negative. Higher
total scores of the F-COPES represent more family coping efforts with
Characteristics of patients and families stressful situations. The F-COPES has strong internal consistency with
Information on the following variates was collected through the Cronbach’s alpha coefficient ranging from 0.61 to 0.87,20,21 and good
questionnaire, including demographic and disease-related character- factorial and concurrent validities.22,23
istics of patients, and demographic characteristics of family members
as well as the whole family. The patient information included age, Development of the Chinese version of F-COPES
gender, subtypes of dementia (Alzheimer's disease, vascular demen- We conducted a rigorous ‘‘forward-backward’’ translation follow-
tia, and others or unknown), dementia severity based on Clinical ing the guidelines to develop the initial Chinese version of F-COPES.24
Dementia Rating evaluated by the physician (moderate, severe), and Then, during the adaptation process, we invited six clinical nurse
time or duration since diagnosis. The information on family members supervisors, nursing researchers, or psychological researchers who
and the whole family included age, educational level (junior middle were professors or associate professors and familiar with both
school and below, high school, college degree, and graduate degree), dementia caregiving and psychometrics to form an expert panel to
 Q. Wang et al. / Geriatric Nursing 45 (2022) 131
139 133

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) 131
139

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)

Characteristics Median (IQR)/%

Results
Demographic and disease-related characteristics of
patients
Table 1 shows the characteristics of patients and families. Among Age, median (IQR), years 82.0 (76.0‒86.0)
the 215 patients, the median age was 82.0 (interquartile range: 76.0‒ Gender
86.0) years old, and 65.1% were women. Alzheimer's disease Female, % 65.1
Male, % 34.9
accounted for 57.2%. The median age of family members was 59.5
Subtypes of dementia
(53.3‒65.0) years old, 60.4% had an educational level of a college Alzheimer's disease, % 57.2
degree or above, and only 6.5% of the family members had religious Vascular dementia, % 29.8
faith. Others or unknown, % 13.0
Dementia severity
Moderate, % 51.2
Content validity
Severe, % 48.8
Time or duration since diagnosis, median (IQR), monthsa 17.5 (7.0‒39.0)
The I-CVIs of 24 items in F-COPES were 1.00. Only the I-CVIs of Demographic of the family members and the whole
items of 12, 20, 25, and 28 were 0.83 (>0.78 is acceptable). The S-CVI family
was equal to 0.98 by calculating the average of the I-CVIs of all items Age, median (IQR), years 59.5 (53.3‒65.0)
Education levelb
(>0.80 is acceptable). Junior middle school and below, % 5.1
High school, % 33.5
Item homogeneity College degree, % 51.6
Graduate degree, % 8.8
Having religious faith (yes)c, % 6.5
Table 2 shows the results of item homogeneity of each item and
Family income per month per person, median (IQR), Chi- 4000.0 (3500.0‒8000.0)
the whole scale. The results of item homogeneity tested by the cor- nese Yuand
rected item-subscale correlation were above 0.20 (ranged from 0.28
Note. aThere were seven missing data
to 0.84), except for items in the subscale of original passive appraisal b
two missing data
(ranged from -0.01 to 0.09). The Cronbach’s alpha coefficient of sub- c
one missing data
d
scales after deleting each item was lower than before, except for 15 missing data.
items in the subscale of original passive appraisal. The results of Continuous variables are expressed as median (interquartile range, IQR), and categori-
cal variables are expressed as percentages
Cronbach’s alpha coefficient had also noticed that the unsatisfactory
results of the subscale of passive appraisal may be mistakes in scoring
the items in this subscale. According to the negative corrected item-
total correlation of items of 12 and 28 in the passive appraisal sub- based on the modified competing model, including six factors, the
scale (-0.26 and -0.50, respectively), we reversed the scoring method correlations between the six factors, the factor-loading from the six
of item 12 and item 28 based on the above results and literature factors of the F-COPES to each item, the square of the factor loading
review. The corrected item-total correlations of item 12 and item 28 of each item, and the correlation between the errors of items based
were positive in the modified subscale of passive appraisal. The on standardized estimates.
results of the corrected item-subscale correlation and Cronbach’s
alpha coefficient of the subscale after deleting each item were Convergent validity
improved.
Table 4 shows the correlation coefficients of each subscale score
Factor structure and the total score of the Chinese version of the F-COPES with the
total score of the MSPSS. The total score of F-COPES had a signifi-
Table 3 shows the fit statistics for the modified original factor cantly strong correlation with the total score of the MSPSS (r = 0.50, P
structure and the modified competing structure of the Chinese ver- < 0.01). The six subscales of the F-COPES significantly correlated
sion of the F-COPES in the present study. In the modified original with the total score of the MSPSS, except for the subscale of seeking
model, we added the correlations between item 2 and item 16, spiritual support.
between item 3 and item 7, item 3 and item 22, and between item 7
and item 22; and we deleted the correlations between the subscale Internal consistency reliability
of seeking spiritual support and the other two subscales of reframing,
and passive appraisal, because the correlations between them were The Cronbach’s alpha coefficient of this measure was 0.86. The
not significant (P>0.05). In the modified competing model, we added Cronbach’s alpha coefficient of subscales based on the competing fac-
the same correlations between items as them in the modified original tor structure was 0.76 for the subscale of acquiring relatives’ support,
model, and deleted the correlations between the subscale of seeking 0.66 for the subscale of acquiring friends’ support, 0.68 for the sub-
spiritual support and the other three subscales of acquiring relatives’ scale of acquiring neighbors’ or others’ support, 0.90 for the subscale
support, reframing, and passive appraisal, because the correlations of seeking spiritual support, 0.85 for the subscale of reframing, and
between them were not significant (P>0.05). All the modifications 0.33 for the subscale of passive appraisal.
were based on theories or hypotheses in the relevant field.
The values of CFI and TLI of both the modified original model and Discussion
the modified competing model marginally reached the criteria, while
the values of x2/df, PGFI, RMSEA met the criteria, indicating that the In the present study in families of patients with dementia in main-
models were acceptable. Additionally, the value of CFI of the modified land China, we developed a Chinese version of the F-COPES based on
competing model is 0.05 higher than that of the modified original the English version and evaluated its psychometric properties. Our Chi-
model, indicating that the competing model was significantly better nese version of this scale showed satisfactory psychometric properties,
than the original one. Fig. 2 shows the factor structure of the F-COPES including content validity, item homogeneity, factor structure,
 Q. Wang et al. / Geriatric Nursing 45 (2022) 131
139 135

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

Acquiring social support 0.84

1 Sharing our difficulties with relatives 0.42 0.53 0.83
2 Seeking encouragement and support from friends 0.28 0.58 0.82
5 Seeking advice from relatives (grandparents, etc.) 0.56 0.55 0.83
8 Receiving gifts and favours from neighbors (e.g., taking in mail, etc.) 0.57 0.58 0.82
10 Asking neighbors for favours and assistance 0.45 0.46 0.83
16 Sharing concerns with close friends 0.57 0.62 0.82
18 Exercising with friends to stay fit and reduce tension 0.45 0.47 0.83
20 Doing things with relatives (get-togethers, dinners, etc.) 0.54 0.57 0.82
25 Asking relatives how they feel about problems we face 0.55 0.64 0.82
Mobilizing the family to acquire and accept help 0.50
4 Seeking information and advice from persons in other families who have faced 0.44 0.35 0.34
the same or similar problems
6 Seeking assistance from community agencies and programs designed to help 0.24 0.31 0.40
families in our situation
21 Seeking professional counselling and help for family difficulties 0.24 0.28 0.45
Seeking spiritual support 0.90
14 Attending worship or religious services in religious places 0.24 0.80 0.87
23 Participating in religious activities 0.25 0.84 0.84
27 Seeking advice from a person in religious places (such as a minister, eminent 0.19 0.78 0.88
monk, etc.)
Reframing 0.85
3 Knowing we have the power to solve major problems 0.53 0.67 0.82
7 Knowing that we have the strength within our own family to solve our 0.59 0.69 0.81
problems
11 Facing the problems “head-on” and trying to get a solution right away 0.49 0.64 0.82
13 Showing that we are strong 0.48 0.62 0.82
15 Accepting stressful events as a fact of life 0.24 0.46 0.84
19 Accepting that difficulties occur unexpectedly 0.36 0.34 0.86
22 Believing we can handle our own problems 0.60 0.74 0.81
24 Defining the family problem in a more positive way so that we do not become 0.42 0.54 0.83
too discouraged
Original passive appraisal 0.06
12 Watching TV -0.26 0.02 0.31
17 Knowing luck plays a big part in how well we are able to solve family problems 0.07 0.09 0.30
26 Feeling that no matter what we do to prepare, we will have difficulty handling 0.12 -0.01 0.20
problems
28 Believing if we wait long enough, the problem will go away -0.50 0.01 0.25
Modified passive appraisal b 0.33
12 Watching TV 0.27 0.14 0.31
17 Knowing luck plays a big part in how well we are able to solve family problems 0.07 0.14 0.30
26 Feeling that no matter what we do to prepare, we will have difficulty handling 0.14 0.23 0.20
problems
28 Believing if we wait long enough, the problem will go away 0.51 0.19 0.25
Note. aIf Cronbach's alpha coefficient of the subscale after deleting an item is higher than before, it means that the item has low homogeneity to other items.
b
Since corrected item-total correlation of item 12 and item 28 in the original subscale of passive appraisal were negative (-0.26 and -0.50, respectively), the scoring method of item
12 and item 28 were reversed, and the corrected item-total correlation, corrected item-subscale correlation, and Cronbach’s alpha coefficient of the subscale after deleting each
item of the modified subscale of passive appraisal were increased.

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) 131
139

Table 3 studies,16,49 perhaps related to different spiritual supporting environ-

Fit statistics for original factor structure model of the Family Crisis Oriented Personal ments and experiences. Only 6.5% of family members have religious
Evaluation Scales and the competing model in the present study (N=215)
faith in our study, and this is much fewer than other populations.52
Models x2/df CFI TLI PGFI RMSEA Families’ behaviors or attitudes reframing or appraising the stress/sit-
a uation in our research are mainly rooted in Confucian introspection,
Modified original model 2.18 0.83 0.81 0.67 0.07
Modified competing model b 1.86 0.88 0.87 0.68 0.06 forbearance, and perseverance, but not religion.50 Familism replaced
a the function of religion in Chinese families and weakened the rela-
Modified original model was established based on the factor structure of the
English version of the Family Crisis Oriented Personal Evaluation Scales. And it was tionship between the coping efforts of acquiring relatives’ support
modified by adding the correlations between item 2 and item 16, between item 3 and and seeking spiritual support.18 Finally, the coping efforts described
item 7, between item 3 and item 22, and between item 7 and item 22 because the in item 2 and item 16, item 3 and item 7, item 3 and item 22, and
modification indices of them were more than 4 and they have similar meanings. It was item 7 and item 22 were recognized as having similar meanings or
also modified by deleting the correlations between the subscale of seeking spiritual
support and the two subscales— reframing, and passive appraisal because the correla-
were correlated with each other as Fig. 2 shows.
tions between them were not significant (P>0.05).
b
In the modified competing model, we made no changes in the following three out Convergent validity
of five subscales in the original model: seeking spiritual support, reframing, and pas-
sive appraisal. For the other two subscales which consist of 12 items totally in the orig-
The F-COPES had a satisfactory convergent validity. The correla-
inal model (i.e., mobilizing the family to acquire and accept help, and acquiring social
support), we rearranged them into three new subscales based on the source of social tion coefficient for the convergent validity of F-COPES was strong
support: namely, acquiring relatives’ support, acquiring friends’ support, and acquiring (the correlation coefficient between F-COPES and MSPSS = 0.50, P <
neighbors’ and others’ support. And we added the same correlations between items as 0.01). Through seeing how closely the new scale is related to other
the modified original model and deleted the correlations between the subscale of seek- measures to which it should be related, this result confirmed that the
ing spiritual support and the three subscales—acquiring relatives’ support, reframing,
and passive appraisal because the correlations between them were not significant
Chinese version of F-COPES could measure family coping well.32 The
(P>0.05).Note. x2/df = chi-square of model fit/df; CFI = comparative goodness-of-fit correlation of the subscale of seeking spiritual support with MSPSS
index; TLI = Tucker-Lewis Index; PGFI = parsimony goodness-of-fit index; was not significant because only 6.5% of family members in the cur-
RMSEA = root mean square error of approximation.The following criteria were used to rent study had religious faith. When they are searching for help, spiri-
determine whether the models fit the data, including 3.00 or lower on the x2 /df; 0.90
tual support is not the common choice.18
or greater on the CFI, and TLI; 0.50 or greater on PGFI; and an RMSEA of 0.08 or lower.
The value of CFI of the model is higher than another model (4CFI>0.01), indicating it
is significantly better than another model. Internal consistency reliability

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) 131
139 137

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) 131
139

Table 4 9. Nojima S, Nakano A, Miyai C. The relationship between the family system and the
Convergent validity of the Chinese version of the Family Crisis Oriented Personal Eval- family coping among families with a chronically ill child. J Jpn Acad Nurs Sci.
uation Scales (N=215) 1994;14(1):28–37. https://doi.org/10.5630/jans1981.14.1_28.
10. Bodenmann G. Dyadic Coping Inventory. In: Simmons C, Lehmann P, eds. Tools for
Subscales of Family Crisis Oriented The correlation coefficient with Strengths-Based Assessment and Evaluation. New York: Springer Publishing Com-
Personal Evaluation Scales the total score of the MSPSS pany; 2013:328–384.
11. Plessis L, Golay P, Wilquin H, Favrod J, Rexhaj S. Internal validity of the French ver-
Acquiring relatives’ support 0.54*** sion of the Family Coping Questionnaire (FCQ): a confirmatory factor analysis. Psy-
Acquiring friends’ support 0.45*** chiatry Res. 2018;269:337–344. https://doi.org/10.1016/j.psychres.2018.08.021.
Acquiring neighbors’ or others’ support 0.34*** 12. Clever K, Schepper F, Maier S, Christiansen H, Martini J. Individual and dyadic cop-
Seeking spiritual support 0.02 ing and fear of progression in mothers and fathers of children with hematologic
Reframing 0.33*** cancer. Fam Process. 2020;59(3):1125–1242. https://doi.org/10.1111/famp.12480.
Passive appraisal 0.22** 13. Hassani P, Abbasi P, Tafreshi MZ, Zayeri F, Ziapour A. Persian version of Family Cri-
Total score 0.50*** sis Oriented Personal Evaluation Scales: psychometric properties. Int J Pediatr.
2018;6(1):6919–6930. https://doi.org/10.22038/ijp.2017.27746.2402.
Note. MSPSS = Multidimensional Scale of Perceived Social Support. 14. Alwi N, Harun D, Omar B, Ahmad M, Zagan M, Leonard JH. The internal reliability of
 p < 0.05;  p < 0.01;  p < 0.001. Family Crisis Oriented Personal Evaluation Scale (F-COPES) in Malay version
among caregivers of individual with learning disabilities. Clin Ter. 2015;166(6):
Funding e361–e364. https://doi.org/10.7417/T.2015.1901.
15. Sari A, Cetinkaya Duman Z. Strategies used by families to cope with chronic mental
illnesses: psychometric properties of the family crisis oriented personal evaluation
This work was supported by the Natural Science Foundation of scale. Perspect Psychiatr Care. 2020;56(2):462–473. https://doi.org/10.1111/
Jiangsu Province (grant number BK20201016), Higher Education Nat- ppc.12457.
16. Lim J, Townsend A. Cross-ethnicity measurement equivalence of family coping for
ural Science Foundation of Jiangsu Province (grant number breast cancer survivors. Res Soc Work Pract. 2012;22(6):689–703. https://doi.org/
20KJB320036), Special Foundation for Promoting Scientific and Tech- 10.1177/1049731512448933.
nological Innovation of Xuzhou City (grant number KC19140) and the 17. Chui WY, Chan SW. Stress and coping of Hong Kong Chinese family members dur-
ing a critical illness. J Clin Nurs. 2007;16(2):372–381. https://doi.org/10.1111/
Higher Education Philosophy and Social Science Foundation of j.1365-2702.2005.01461.x.
Jiangsu Province (grant number 2019SJA0944). The funders had no 18. Liang S. Outline of Chinese culture. Shanghai: Shanghai People's Publishing House;
direct role in the design, data collection, analysis, interpretation, or 2005.
19. Kim K. The relation among fit indexes, power, and sample size in structural equa-
writing of the manuscript. tion modeling. Struct Equ Model. 2005;12:368–390. https://doi.org/10.1207/
s15328007sem1203_2.
Declaration of Competing Interest 20. Coyne E, Dieperink KB, Ostergaard B, Creedy DK. Strengths and resources used by
Australian and Danish adult patients and their family caregivers during treatment
for cancer. Eur J Oncol Nurs. 2017;29:53–59. https://doi.org/10.1016/j.
The authors declared no potential conflicts of interest concerning ejon.2017.05.005.
the research, authorship, and/or publication of this article. 21. Ahlert IA, Greeff AP. Resilience factors associated with adaptation in families with
deaf and hard of hearing children. Am Ann Deaf. 2012;157(4):391–404. https://doi.
org/10.1353/aad.2012.1629.
Consent for publication 22. Tay KC, Seow CC, Xiao C, Lee HM, Chiu HF, Chan SW. Structured interviews exam-
ining the burden, coping, self-efficacy, and quality of life among family caregivers
of persons with dementia in Singapore. Dementia (London). 2016;15(2):204–220.
Not applicable. https://doi.org/10.1177/1471301214522047.
23. Son H, Friedmann E, Thomas SA, Son YJ. Biopsychosocial predictors of coping strat-
egies of patients postmyocardial infarction. Int J Nurs Pract. 2016;22(5):493–502.
Acknowledgment
https://doi.org/10.1111/ijn.12465.
24. Sousa VD, Rojjanasrirat W. Translation, adaptation and validation of instruments or
Not applicable. scales for use in cross-cultural health care research: a clear and user-friendly
guideline. J Eval Clin Pract. 2011;17(2):268–274. https://doi.org/10.1111/j.1365-
2753.2010.01434.x.
Availability of data and materials 25. Yuan S, Wang F, Li X, Jia M, Tian M. Facilitators and barriers to implement the fam-
ily doctor contracting services in China: findings from a qualitative study. BMJ
Open. 2019;9:(10) e032444. https://doi.org/10.1136/bmjopen-2019-032444.
The datasets during and/or analyzed during the current study are
26. Dai B, Mao Z, Wu B, Mei YJ, Levkoff S, Wang H. Family caregiver's perception of Alz-
available from the corresponding author on reasonable request. heimer's disease and caregiving in Chinese culture. Soc Work in Publ Health.
2015;30(2):185–196. https://doi.org/10.1080/19371918.2014.969858.
27. Kapp L, Brown O. Resilience in families adapting to autism spectrum disorder. J Psy-
References chol Afr. 2011;21(3):459–464. https://doi.org/10.1080/14330237.2011.10820482.
28. Chinese General Social Survey. 2017. http://cnsda.ruc.edu.cn/index.php?r=proj-
1. World Health Organization. Dementia. 2021-02-27; http://www.who.int/news- ects/view&id=94525591.Accessed 2022-01-19.
room/facts-in-pictures/detail/dementia. Accessed 2022-1-19. 29. Zimet GD, Powell SS, Farley GK, Werkman S, Berkoff KA. Psychometric characteris-
2. Center for Disease Control and Prevention. Caregiving for Person with Alzheimer's tics of the Multidimensional Scale of Perceived Social Support. J Pers Assess.
Disease or a Related Dementia. 2019-10-30; https://www.cdc.gov/aging/caregiv 1990;55(3-4):610–617. https://doi.org/10.1080/00223891.1990.9674095.
ing/alzheimer.htm. Accessed 2022-1-19. 30. Lynn MR. Determination and quantification of content validity. Nurs Res. 1986;35
3. Maguire KC. Stress and Coping in Families. Cambridge: Polity Press; 2012. (6):382–385. https://doi.org/10.1097/00006199-198611000-00017.
4. Villarejo Galende A, Eimil Ortiz M, Llamas Velasco S, Llanero Luque M, Lopez de 31. Polit DF, Beck CT. Nursing Research: Principles and Methods. 7th ed. Philadelphia:
Silanes de Miguel C, Prieto Jurczynska C. Report by the Spanish Foundation of the Lippincott, Williams, & Wilkins; 2004.
Brain on the social impact of Alzheimer disease and other types of dementia. Neu- 32. Streiner D, Norman G. Health Measurement Scales: a Practical Guide to their Develop-
rologia. 2021;36(1):39–49. https://doi.org/10.1016/j.nrl.2017.10.005. ment and Use. New York: Oxford University Press; 2008.
5. Ransmayr G, Hermann P, Sallinger K, et al. Caregiving and caregiver burden in 33. Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of per-
dementia home care: results from the prospective dementia registry (PRODEM) of ceived social support. J Pers Assess. 1988;52(1):30–41. https://doi.org/10.1207/
the Austrian Alzheimer Society. J Alzheimers Dis. 2018;63(1):103–114. https://doi. s15327752jpa5201_2.
org/10.3233/JAD-170657. 34. Fei X.From the Soil: The Foundations of Chinese Society. Shanghai: Shanghai Peo-
6. McCubbin HI, Thompson A, McCubbin MA. Family Measures: Stress, Coping And ple's Publishing House; 2006.
Resiliency-Inventories for Research and Practice. Honolulu: Kamehameha Schools; 35. McCubbin HI, Thompsom AI. Family Assessment Invertories for Research and Prac-
2001. tice. Madison: The University of Wisconsin-Madison; 1991.
7. Robinson-Lane SG, Zhang XY, Patel A. Coping and adaptation to dementia family 36. Kang H, Ahn JW. Model setting and interpretation of results in research using
caregiving: a pilot study. Geriat Nurs. 2021;42(1):256–261. https://doi.org/ structural equation modeling: a checklist with guiding questions for reporting.
10.1016/j.gerinurse.2020.08.008. Asian Nurs Res. 2021;15(3):157–162. https://doi.org/10.1016/j.anr.2021.06.001.
8. Magliano L, Guarneri M, Marasco C, Tosini P, Morosini PL, Maj M. A new question- 37. Carmines EG, McIver JP. Analyzing models with observable variables. In:
naire assessing coping strategies in relatives of patients with schizophrenia: devel- Borgatta EF, Bohrnstedt GW, eds. Social Measurement: Current Issues. Beverly Hills:
opment and factor analysis. Acta Psychiatr Scand. 1996;94(4):224–228. https://doi. Sage Publications; 1981.
org/10.1111/j.1600-0447.1996.tb09853.x.
 Q. Wang et al. / Geriatric Nursing 45 (2022) 131
139 139

38. Bentler PM. Comparative fit indexes in structural models. Psychol Bull. 1990;107 48. Youngblut JM, Brooten D. What children wished they had/had not done and their
(2):238–246. https://doi.org/10.1037/0033-2909.107.2.238. coping in the first thirteen months after their sibling's neonatal/pediatric intensive
39. Tucker LR, Lewis C. Reliability coefficient for maximum likelihood factor analysis. care unit/emergency department death. J Palliat Med. 2020;24(2):226–232.
Psychometrika. 1973;38(1):1–10. https://doi.org/10.1007/BF02291170. https://doi.org/10.1089/jpm.2019.0538.
40. Joreskog KG, Sorbom D. LISREL 8: User's Reference Guide. LISREL 8: User’s Reference 49. Guada J. The unique coping strategies of African American families with a loved
Guide. Chicago: Scientific Software International; 1996. one with schizophrenia: the Use of the Family Crisis Oriented Personal Evaluation
41. Bentler PM, Bonett DG. Significant tests and goodness of fit in the analysis of Scale. J Fam Soc Work. 2012;15(3):171–186. https://doi.org/10.1080/
covariance structure. Psychol Bull. 1980;88:588–606. https://doi.org/10.1037/ 10522158.2012.67562550.
0033-2909.88.3.588. 50. Wang X, Shi M. A study of Chinese stress coping: Emic and etic approach. Adv in
42. Brown MW, Cudeck R. Alternative ways of assessing model fit. In: Bollen KA, Psych Sci. 2013;21(7):1239–1247.
Long JS, eds. Testing Structural Equation Models. Newbury Park, CA: Sage Publica- 51. Wang Q, Sheng Y, Wu F, Zhang Y, Xu X. Effect of different sources support on adap-
tions; 1993:136–162. tation in families of patient with moderate-to-severe dementia in China. Am J Alz-
43. Cheung GW-K, Rensvold RB. Evaluating goodness-of-fit indexes for testing mea- heimers Dis Other Demen. 2019;34(6):361–375. https://doi.org/10.1177/
surement invariance. Struct Equ Model. 2002;9(2):233–255. https://doi.org/ 1533317519855154.
10.1207/S15328007SEM0902_5. 52. Rush CL, Lobo T, Serrano A, Blasini M, Campos C, Graves KD. Complementary and
44. Pihet S, Kipfer S. Coping with dementia caregiving: a mixed-methods study on fea- alternative medicine use and Latina breast cancer survivors' symptoms and func-
sibility and benefits of a psycho-educative group program. BMC Geriatr. 2018;18 tioning. Healthcare (Basel). 2016;4(4):80. https://doi.org/10.3390/health-
(1):209. https://doi.org/10.1186/s12877-018-0896-y. care4040080.
45. Khamis H. Measures of Association: How to Choose? J Diagn Med Sonogr. 2008;24 53. Wilks SE, Little KG, Gough HR, Spurlock WJ. Alzheimer's aggression: influences on
(3):155–162. https://doi.org/10.1177/8756479308317006. caregiver coping and resilience. J Gerontol Soc Work. 2011;54(3):260–275. https://
46. DeVellis RF. Scale development theory and application. Scale development theory doi.org/10.1080/01634372.2010.544531.
and application. London: Sage Publications; 1991. 54. Waltz CF, Strickland OL, Lenz ER. 4th Measurement in nursing and health research.
47. Kim SM, Han DH, Trksak GH, Lee YS. Gender differences in adolescent coping behav- 4th ed. New York: Springer Publishing Company; 2010.
iors and suicidal ideation: findings from a sample of 73,238 adolescents. Anxiety
Stress Coping. 2014;27(4):439–454. https://doi.org/10.1080/10615806.2013.876010.