China has the world's largest elderly population, and this group is associated with a higher prevalence of chronic health conditions.1,2 Hypertension is the single most important risk factor for cardiovascular death and disability, conditions that have been prevalent with older age in recent decades.3 In China, 50.1% of the elderly population, which is more prone to have target organ damage, experience hypertension.4 Lu et al4 found that only 7.2% of Chinese adults were in control of their blood pressure and 44.7% were aware of their diagnosis; both findings were related to low educational achievement. Until 2006, the proportion of the older adults who had no formal education or only a primary education had increased to 72.5% in China.5 Poor control and lack of hypertension awareness will often seriously affect a patient's quality of life, especially among the older adults. Self-care, as an effective method of secondary prevention of hypertension, has been documented as one of the main determinants of hypertension control.6,7
A literature review shows that several of the following instruments of measuring self-care ability among the older adults with hypertension are in use. The Exercise of Self-Care Agency scale has been confirmed to be valid and reliable and has been used for a long time.8 However, as a generic scale, it lacks disease specificity. The Hypertension Patients Self-Management Behavior Rating Scale9 is a self-designed scale, which has been confirmed to be valid and reliable in Chinese samples. However, it limits the evaluation of the effectiveness of the self-care intervention. Hypertension Self-Care Profile10 is a valid and reliable scale with 60 items. Although it encompasses comprehensive domains of hypertension self-care behaviors, it limits the evaluation of the effectiveness of self-care intervention. The Hypertension Self-Care Activity Level Effects11 is a valid and reliable instrument. It is suitable for large-scale epidemiological investigations. In view of this, Dickson et al12 developed a 23-item Self-care of Hypertension Inventory (SC-HI) based on the middle-range theory of self-care; the inventory could evaluate the effectiveness of the self-care intervention and filled an important gap in the literature. Silveira et al13 cross-culturally adapted it to Brazilian Portuguese. Psychometric testing illustrated that the SC-HI was a reliable and valid instrument for measuring self-care in patients with hypertension. It is suitable for the older adults with its simple and easy-to-understand items.
Given the large size of the elderly population, the importance of this instrument, and the lack of any available similar instrument in China, we aimed to cross-culturally adapt the SC-HI to Chinese and apply it in a preliminary sample of elderly patients with hypertension to evaluate its measurement properties in clinical practice and research.
Patients were recruited from 1 of 4 tertiary care hospitals if they were 60 years or older,14 were on antihypertensive medications, were able to communicate and understand the questionnaire,10,12 and provided informed consent. Patients were excluded if they had acute or terminal conditions, for example, myocardial infarction or terminal cancer; psychiatric diagnoses, for example, schizophrenia or cognitive impairment; or other conditions that precluded participation in the study.10 This study was approved by the institutional review board of the Affiliated Hospital of Nantong University.
Translation and Adaptation Procedure
The guidelines for the translation and cultural adaptation of the self-report measures, as recommended by Beaton et al,15 were used in our study (Figure).
After obtaining authorization to translate the questionnaire, 2 native Chinese-speaking research professionals, A and B, independently translated the SC-HI into Chinese (T1, T2, translation step). Subsequently, a third individual, C, prepared a consensus for the final translated version (T12, synthesis step). Then, individuals D and E translated T12 back into English blindly to ensure that the meanings of all items were maintained (back-translation step). A consensus was provided on the back-translated version for review (BTR, back-translation review step). Individual F subsequently compared the BTR with the original source to avoid information bias in the translated questionnaire (T12). After that, we submitted both T12 and the BTR to the authors for their appraisals of the translation equivalence (submission to authors step).
The expert committee comprised a methodologist and 5 bilingual specialists with experience in healthcare for the older adults with hypertension. To ensure the scale could be understood by the equivalent of a 12-year-old (roughly a grade 6 level of reading), as is the general recommendation for questionnaires,15 the committee culturally adapted the Chinese SC-HI. Then, they evaluated content validity and equivalence between the source and the adapted version in 4 areas: semantic, conceptual, idiomatic, and experiential equivalences (expert committee review step).15–18 Last, this adapted SC-HI was submitted to the authors again for reevaluation of the translation consistency (submission to authors step).
We then pretested the self-administered instrument on 30 target patients with different education levels, using a one-on-one interview to ensure patients' understanding and the cultural relevance of each item (pretesting step). Meanwhile, the problems existing in the survey scale were recorded and modified. After obtaining agreements for each item among patients and experts, a final Chinese SC-HI was produced.
All analyses were performed with SPSS 20.0. The characteristics of the participants were examined via frequency and percentage distributions. Continuous variables are expressed as the means. The content validity was calculated with a content validity index, and before that, interrater agreement was computed during the cultural adaptation process.18 Internal consistency was measured using Cronbach α. We calculated the test/retest reliability using the intraclass correlation coefficient between 2 sets of scores obtained 2 weeks apart and analyzed these results with the paired samples t test. The Pearson correlation was applied for the item-total correlation, and principal factor analysis was used to identify and score dimensionality of the items in the 3 subscales of SC-HI, respectively, as previously reported.12 Factor analysis aimed to ascertain the number of latent variables that explain most of the variance in a given data set.19P < .05 was considered statistically significant.
Because the required sample size was 5 to 10 times the number of survey items, a total of 220 survey questionnaires were handed out and recovered on the spot, with a recovery rate of 100%. Among the included participants, 120 (54.5%) were male and 100 (45.6%) were female. The mean age and duration of hypertension were 73.74 (8.97) years (range, 60–73 years) and 14.28 (11.57) years (range, 1 month to 64 years), respectively. Eighteen respondents (8.2%) had stage I hypertension, 60 (27.3%) had stage II hypertension, and 142 (64.5%) had stage III hypertension.
Translation and Cross-cultural Adaptation
During the back-translation process, problems such as missing words and unexpected meanings of the items were resolved in a timely manner. Moreover, we obtained the authors' approval of the BTR. So far, the semantic equivalence between the target version and the original source has been basically achieved.
For ease of understanding and to facilitate administration,13 the first sentence of the Self-care Management and items 2, 3, 5, 6, 12, 16, and 17 were modified slightly (Table) based on Chinese culture, the medical environment of the mainland, and the comprehension ability of the target patients. The first sentence of the Self-care Management was expanded to include “circle one alternative”; items 2, 5, 12, 16, and 17 were modified as “Eat more fruits and vegetables,” “Low-salt diet,” “How quickly did you recognize that your blood pressure rose?”, “Seek guidance from doctors/nurses,” and “How sure were you that the action helped?” Items 3 and 6 were added as “Do some physical activity (such as taking a walk, climbing stairs and gardening)” and “Exercise for 30 minutes every day.”
Interrater agreement was 0.782 in this research, indicating that there was an acceptable level of reviewer agreement about using the rating scale. Moreover, the item-level content validity index was 0.833 to 1, and the scale-level content validity average method was 0.986 of the Chinese adapted SC-HI, indicating that it was content valid.17,20
Acceptability and Feasibility
The male-female proportion was 2:1 during the pretesting step. Participants completed the questionnaires in 8 to 10 minutes, with an item omission rate of 0%. In addition, the pretesting showed that the adapted Chinese SC-HI could be accepted and understood by the older adults when presented in a comfortable layout.
Adapted Chinese Version of the Self-Care of Hypertension Inventory
The adapted Chinese SC-HI is a self-rating scale that includes 23 items divided across 3 subscales: Self-care Maintenance (items 1–11), Self-care Management (items 12–17), and Self-care Confidence (items 18–23). The Self-care Maintenance domain includes self-monitoring and treatment adherence, with scores ranging from 1 to 4 (“never or rarely” to “always or daily”). In the Self-care Management domain, 1 item about recognizing symptoms ranges from 0 to 4 to capture a fully negative response (“I did not recognize it” to “very quickly”). The other 4 items about dealing with symptoms are scored from 1 to 4 (“not quickly” to “very quickly”). The remaining item about evaluating the intervention effectiveness is scored from 0 to 4 (0, “I did not try anything”; 1, “not sure”; to 4, “very sure”).12,13 Finally, in the Self-care Confidence domain, 6 items are all scored from 1 to 4 (“not confident” to “extremely confident”). Scores were calculated for each scale individually, as shown in the Table.13
Preliminary Application of the Chinese Version of the Self-care of Hypertension Inventory
The item-total correlation coefficients varied from 0.212 to 0.446 (P < .01), except for item 2 on the Self-care Maintenance scale. For the Self-care Management scale and the Self-care Confidence scale, the item-total correlation coefficients were in a range of 0.419 to 0.668 and 0.439 to 0.663, respectively (P < .01). In addition, the Cronbach α coefficients for the total scale and the 3 dimensions were .858, .690, .703, and .891, respectively. The intraclass correlation coefficient was 0.949 (95% confidence interval, 0.864–0.996; P < .01) for the total scale and greater than 0.700 for the 3 dimensions. In addition, principal factor analyses showed the presence of 4, 1, and 1 latent factors with eigenvalues greater than 1, explaining 63.619%, 42.642%, and 65.136% of the total variance, in Self-care Maintenance, Management, and Confidence, respectively.
This was the first Chinese study to translate, cross-culturally adapt, and preliminarily test the modified SC-HI among elderly patients with hypertension. It was found valid and reliable as a measurement of self-care abilities of patients with hypertension at each stage of the self-care process (maintenance, management, and confidence).12
During the cross-cultural adaptation process, some terms and expressions were modified or added to facilitate the understanding of scale items by patients and experts. For instance, “Call your doctor/nurse for guidance” was substituted for “Seek guidance from doctors/nurses” because patients treated through the public health system would not call doctors or nurses in China. During pretesting, patients could understand all items accurately and respond considering their own actual situations.
Cronbach α coefficients were acceptable and basically consistent with the original study.12 The intraclass correlation coefficient calculated using a test/retest method was also high (0.949), indicating the strong stability of SC-HI over time, as reported in the previous study.13 Moreover, the item-specific analysis showed that item 2 had poor fit with the total scale (r = 0.165). However, it had good fit with the Self-care Maintenance scale (r = 0.412), and internal consistency was not improved with its removal. This may be related to patients' differing concepts regarding each dimension. Because of differences in living habits, the older adults in China have paid less attention to eating more fruits than Americans have. Therefore, we kept this item in the adapted SC-HI. The results related to principal factor analyses confirmed the presence of 4 factors of exercise (items 3, 5, and 6), alimentary control (items 2 and 10), medication adherence (items 7 and 9), and symptom control (items 1, 4, 8, and 11) in the Self-care Maintenance scale and 1 single factor in the other 2 subscales; these findings suggest that the Self-care Maintenance scale is a multidimensional construct and that the other 2 subscales are unidimensional instruments.
In this study, we applied the adapted SC-HI to a sample of elderly patients with hypertension. The results showed that participants with stage III hypertension and a long duration of hypertension had better self-care ability than other participants. A possible explanation is that participants with stage III hypertension would have several complications that affect their quality of life and they must keep diets, activities, and emotions in strict control to control diseases. The longer the duration of their hypertension, the more health education they will get. Hence, those who had a long duration of hypertension would acquire more health-related knowledge. In addition, the results indicated that this study was conducted with a large age span of the research subjects; more studies comparing self-care ability in different age groups could be conducted.
Given the increasing number of elderly patients with hypertension, it is important to focus on older individuals to help them exercise their potential for self-care in maintaining their health and well-being in everyday life. Because hypertension is a chronic and often asymptomatic disease,13 self-care in hypertension poses challenges to providers, patients, and caregivers. However, it is still an important aspect of disease management. Not only does the SC-HI assess self-care behaviors effectively, but it also provides for the evaluation of self-care intervention effectiveness.
The SC-HI has been translated and cross-culturally adapted successfully to Chinese. In the future, as research evolves, this instrument should be further explored in other groups with hypertension with larger sample sizes.
What's New and Important
- The authors of this study are the first to conduct a cross-cultural adaptation of the SC-HI for use among older Chinese adults.
- The authors of this study provide an initial validation of an instrument to evaluate self-care among elderly Chinese patients with hypertension.
The authors thank Jianle Ni, Wangqin Shen, and Duanying Cai for their contributions to the translation phases and Jiayu Li and Fan Wu for their contributions to the data collection.
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