Cultural Adaptation and Psychometric Validation of a Cardiac Knowledge Questionnaire for Chinese Immigrants

Abstract

Background 

Disease-related knowledge deficits are common in Chinese immigrants living in Western countries, putting them at risk of disease progression and mortality, particularly those with a coronary heart disease (CHD) diagnosis. However, no measurement instrument is available to assess CHD-related knowledge in this population.

Objectives 

The aim of this study was to culturally adapt and examine the psychometric properties of the short version of Coronary Artery Disease Education Questionnaire (CADE-Q SV) (simplified Chinese version) in Chinese immigrants with CHD.

Methods 

Mandarin-speaking people recruited from medical centers and cardiology clinics across metropolitan Sydney completed the 20-item CADE-Q SV (5 domains; potential scores: 0–20). Internal consistency was assessed using Cronbach α. A subgroup (n = 40) repeated the survey 2 weeks later for test-retest reliability by intraclass correlation coefficient. Factor structure (confirmatory factor analysis) and discriminant (known-groups) validation using education and English proficiency (univariate general linear model) were also undertaken.

Results 

Participants (n = 202) had a mean (SD) age of 66.08 (10.93) years, 45.1% were male, and the mean (SD) total CADE-Q SV score was 13.07 (4.57). Reliability and consistency were good (intraclass correlation coefficient > 0.70; Cronbach α coefficients > 0.70, for total and per domain, respectively). The 5-domain structure was validated by confirmatory factor analysis. The scale demonstrated discriminant validity, with low education (P < .001) and low English proficiency (P = .017) associated with lower knowledge scores.

Conclusion 

The CADE-Q SV (simplified Chinese version) can be used as a valid and reliable instrument, either paper based or digital, to evaluate the CHD-related knowledge of Chinese immigrants. This scale can be adapted to other migrant populations in the future.

Global migration has grown dramatically over the past 2 decades, with an estimation of 281 million international migrants living outside their country of origin in 2020.^1,2 Of these, most (65%) migrated to high-income countries in response to global economic, education, and family reunification, and humanitarian changes.^1,2 Diversity through immigration is common in Western countries.³ Statistics showed that migrants comprised almost 1 in 6 people residing in high-income countries.¹ Migration affects a person's life in various aspects, including socioeconomic, cultural, and psychological status, all of which can also substantially impact their health.⁴

Chinese immigrants, indicating a population who were born in Mainland China, Hong Kong, Macau, and Taiwan and living in a country other than those mentioned, are one of the largest immigrant populations worldwide and frequently demonstrate poor proficiency in local languages such as English.^3,5–7 Deficits in the English language limit acquisition of health information, including health promotion and secondary prevention information.^8,9 Thus, disease-related knowledge deficits are common in Chinese immigrants, putting them at risk of disease progression and mortality, which is evident in immigrants with coronary heart disease (CHD) diagnoses.^10,11

Improving patients' knowledge is an important secondary prevention strategy.^9,12 Coronary heart disease remains the leading cause of death worldwide.¹³ It is a chronic disease, with 40% of patients experiencing recurrent events, ultimately contributing to an increased burden on the individual, their families, and healthcare systems.^14,15 An estimated 75% of these recurrent events could be prevented by engagement in secondary prevention to manage modifiable risk factors.¹³ Recognition of secondary prevention knowledge needs is an important step in the process, and particularly so in populations at risk, such as immigrants. Cardiovascular disease is one of the most challenging health problems affecting ethnic minorities and immigrants in many immigrant-receiving countries.^10,16 Chinese immigrants experience disadvantageous cardiovascular disease profiles, with increased cardiovascular disease risk factors and prevalence, and worsening health-related outcomes, including higher mortality.^10,17,18 Our understanding of CHD-related knowledge of Chinese immigrants and the impact of educational initiatives are limited by the lack of an appropriate validated questionnaire.

The Short Version of the Coronary Artery Disease Education Questionnaire (CADE-Q SV) is a potentially suitable instrument to assess disease-related knowledge in culturally diverse cardiac populations. The instrument was developed from an original questionnaire (CADE-Q), which was psychometrically validated to assess patients' knowledge about CHD in Brazilian patients attending cardiac rehabilitation.¹⁹ A subsequent version was translated, cross-culturally adapted, and psychometrically validated for English-speaking populations,²⁰ and an expanded version (31-item CADE-Q II) was created.²¹ Additional knowledge components were added, such as psychosocial health and nutrition.²¹ However, both instruments take around 20 minutes to complete, and there is an evident need for a shorter simple instrument to assess cardiac patients' knowledge in clinical practice. A reduced 20-item CADE-Q SV was then developed in 12 languages (including a simplified Chinese version), which has been repetitively proven to have high levels of reliability and validity.^22–24 However, the performance of the CADE-Q SV (simplified Chinese version) has not been assessed in an immigrant population. Indeed, Chinese immigrants' CHD knowledge needs have often been neglected.²⁵

Awareness of the cultural adaptation process to the specific context may be essential when adapting questionnaires to another language and other countries, particularly in an immigrant population.²⁶ Although the CADE-Q SV (simplified Chinese version) has been previously validated in residents of China, there is a need to adapt the content to Chinese-speaking people who are living in other countries, including English-speaking countries.²³ Migration to high-income countries can affect a person's lifestyle, such as food choices and exercise habits.¹⁰ For Chinese immigrants with CHD, the scope of knowledge regarding disease, risk factors, and health behaviors could differ, as well as different recommendations for CHD in other countries. Thus, a valid culturally adapted instrument should be used to assess their disease-related knowledge accurately. In this study, our aim was to validate the psychometric properties of the CADE-Q SV (simplified Chinese version) culturally adapted for Chinese immigrants with CHD in Australia.

Method

Sample and Data Collection

Between May and November 2021, Chinese immigrants with CHD were recruited from 5 participating medical centers and cardiology clinics that have a high proportion of Chinese immigrants residing in metropolitan Sydney, Australia. Patients were considered eligible if they were (1) born in Mainland China, Hong Kong, Taiwan, or Macao and living in Australia; (2) Mandarin speakers with a sufficient understanding of simplified Chinese for consent and questionnaire processes; (3) given a diagnosis of CHD (including acute coronary syndrome and myocardial infarction); and (4) able and willing to provide informed consent. Exclusion criteria included (1) younger than 18 years and (2) having a significant visual or cognitive condition or severe mental illness, which would limit the participant's ability to answer the questionnaires. A sample size of 200 was calculated based on Hair et al's²⁷ recommendation of 10 subjects per item, with the CADE-Q SV having 20 items. A sample size of 40 was determined for the repeat test-retest assessment.

Potential participants were identified by physicians during their visits and provided with study information by the recruiter in person or via phone call, mail, or email, according to their preference and COVID pandemic restrictions. Interested patients provided informed consent and then undertook the survey either via a hard copy or a digital REDCap link through a QR code. Hard copies were completed either at the clinics or at home. For those who preferred to complete the questionnaire at home completed questionnaires or scanned copies and returned these to the recruiter by person, mail, or email within a week. They were advised to complete the questionnaire alone without assistance from others. Participants were sent an email or text reminder to return the completed survey in 1 week.

Participants were asked about their interest in undertaking a repeat survey in 2 weeks—participants opted in to the repeated survey with a digital survey link sent via email or text message. Sociodemographic information was collected using a self-reported questionnaire with multiple choices and free-text response questions. Digital data were collected using the REDCap platform, and paper-based data were entered into the same platform. Human Research Ethics and Governance Committee approval was granted for all participating sites in this study (ref. 2021/219), and each participant provided written informed consent.

Measures

The 20-item CADE-Q SV has 5 domains with 4 items in each domain: medical condition, risk factors, exercise, nutrition, and psychosocial risk.^22,24 Each item provides a statement with the possible response options: true, false, or I don't know. One point is scored for each correct answer, and no point was given for wrong or “don't know” answers; therefore, the maximum total score is 20, and the maximum score for each domain is 4.²² Respondents take a mean (SD) of 7 (2) minutes to complete the English version.²²

The simplified Chinese version has been translated and culturally adapted for use in cardiac patients in Mainland China and psychometrically assessed using confirmatory factor analysis (CFA).²³ In the current study, the CADE-Q SV (simplified Chinese version) has been culturally adapted based on recommendations arising from a study conducted in a community sample of Chinese immigrants with CHD in the Greater Sydney Area, New South Wales, Australia.^28,29

Cultural Adaptation

The cultural adaptation process for this study on immigrants was based on the simplified Chinese version of CADE-Q SV from Mainland China.²³ The process included an evidence search of current national and international clinical guidelines and systematic reviews for CHD, risk factors, nutrition, exercise, and psychosocial health.^12,30–35 In addition, a panel of 2 bilingual nurse researchers and 2 bilingual cardiac clinical nurse specialists reviewed the list of questions and provided adaptations according to the searched evidence, their clinical experiences, and their knowledge base. For instance, in question 12, the daily salt intake has been altered from 6 grams to 5 grams; modifications were made to the translated terms “stress coping” and “risk factor” to clarify the meanings. After adaptations, the questionnaire was administered to a pilot of 5 Chinese immigrants with CHD to ensure readability before the finalization (Supplementary File Table S1, https://links.lww.com/JCN/A194).

Statistical Analysis

Data were exported from the REDCap platform into SPSS version 27.0 (IBM Corp) for cleaning and analyzing. Sociodemographic and clinical characteristics are presented as mean (SD) for continuous variables and n (%) for categorical variables. Statistical significance was set at α < .05 for all the analyses. The distribution of the total CADE-Q SV (simplified Chinese) score and residuals from the multivariable analysis were assessed to determine whether they met the assumptions for the analyses.

The psychometric properties were assessed following the recommended quality criteria, including evidence for reliability, validity, and factor structure.³⁶ First, test-retest reliability in the convenience sample of 40 participants was assessed by the intraclass correlation coefficient, with values of 0.50 to 0.75, 0.75 to 0.90, and >0.90 indicating moderate, good, and excellent reliability.³⁷ Second, Cronbach α was calculated for the total score and each domain to test internal consistency reliability, with values ≥ 0.70 considered acceptable, reflecting the internal correlation between items of the same domain.²⁷

Third, exploratory factor analysis was performed to confirm the suitability for CFA assessed by Kaiser-Meyer-Olkin measure of sampling adequacy and Bartlett's test of sphericity (Kaiser-Meyer-Olkin = 0.784, χ² = 1554.26, P < .001).³⁸ After that, the factor structure was assessed by CFA. Previously, Ghisi et al²⁴ had identified 5 factors in their study (English version), and Yang et al²³ then found the 5-factor model acceptable (simplified Chinese version); thus, in this study, we tested the same model using SPSS Amos version 27. A variety of indices were tested, including the χ²/df ratio, goodness-of-fit index (GFI) and adjusted GFI, comparative fit index, and root mean square error of approximation and 95% confidence intervals, to evaluate the quality of the model. In the current study, the model was considered adequate if the comparative fit index, GFI, and adjusted GFI were close to or greater than 0.90,^38,39 preferably greater than 0.95,⁴⁰ and the root mean square error of approximation was less than 0.08, preferably less than 0.05.⁴¹ If any of these statistics indicated inadequate fit, the modification indices provided in the Amos output were used to respecify the model.

Multivariable linear regression was used to assess discriminant (known-groups) validation, defined as the extent to which scores on a measure distinguish between individuals or populations that would be expected to differ.^42–44 We expected people with higher educational qualifications and better English literacy would have higher disease-related knowledge, based on existing literature.^45–48

Results

Participant Characteristics

In total, 252 patients were approached, and 204 consented and participated (55 paper-based and 149 digital survey responses, 80% response rate). There was no statistically significant difference found in total scores between the paper-based (mean [SD], 12.98 [4.01]) and digital surveys (mean [SD], 13.06 [4.78]) (P = .914). Most of the surveys (n = 196, 96%) were completed by participants at the clinic while waiting for their appointment. Survey completion took a mean (SD) of 9 (3) minutes, and 202 responses with complete CADE-Q SV data were available for analysis. Participants had a mean (SD) age of 66.08 (10.93) years; 45.1% were male, and most were married (84.8%) (Table 1). Of these, 152 participants (74.5%) were unemployed or retired, 70.1% had completed tertiary or higher levels of education, and most did not speak English (70.1%). Education related to CHD was delivered by healthcare providers (70%), and few (<10%) attended cardiac rehabilitation programs.

TABLE 1 - Sociodemographic Characteristics of Participants (N = 202)

Characteristics		n	%
Age, mean (SD), y		66.08	10.93
Age (dichotomous), y	65+	119	58.3
	<65	82	40.2
	Missing	3	1.5
Gender	Male	92	45.1
	Female	112	54.9
Marital status	Married	173	84.8
	Not married	31	15.2
Working status	Employed	52	25.5
	Unemployed	152	74.5
Education level	Below tertiary	61	29.9
	Tertiary education and higher	143	70.1
Education provider	Healthcare providers	142	70.3
	Self-learn	60	29.7
	Missing	2	1.0
English literacy	Yes	61	29.9
	No	143	70.1
Time from CHD diagnosis, y	Less than 1	70	34.5
	Between 1 and 5	74	36.5
	More than 5	59	29.1
Cardiac rehabilitation attendance	Yes	18	8.9
	No	185	91.1

Abbreviation: CHD, coronary heart disease.

Psychometric Properties

The mean scores per domain and per item of CADE-Q SV are presented in Table 2. The total mean (SD) score was 13.07 (4.57) out of a potential 20. The nutrition domain had the highest mean (SD) score of 3.23 (1.16) out of 4, whereas the lowest score was for psychosocial (mean [SD], 1.91 [1.57]). The highest mean score per item was 1 (mean [SD], 0.96 [0.26]), whereas the lowest was 7 (mean [SD], 0.35 [0.48]).

TABLE 2 - Short Version of Coronary Artery Disease Education Questionnaire Score (Item Score Mean, Intraclass Correlation Coefficient, Item Total Score Correlations, Cronbach α Coefficients, and Mean Scores per Domain)

Domain	Item No. and Description	Item Score, Mean (SD)	ICC (n = 40)	Item Total Score Correlations	Cronbach α Coefficients per Domain	Mean (SD) Score per Domain With 95% CI
1. Medical	1. Coronary artery disease is a disease of the arteries in the heart that only happens in older people who have high cholesterol or smoke.	0.49 (0.50)	0.96	0.668	0.787	2.18 (1.52)	1.96–2.38
	3. “Angina” is chest pain or discomfort, at rest or during physical activity, which can be felt in the arm, back, and/or neck.	0.67 (0.47)	0.85	0.624
	6. Antiplatelet medications such as aspirin (ASA) are important because they lower the “stickiness” of platelets in the blood that blood flows more easily through the coronary arteries and past coronary stents.	0.64 (0.48)	0.84	0.403
	11. The “statin” medications limit how much cholesterol the body absorbs from food. Statin medications include atorvastatin (Lipitor), rosuvastatin (Crestor), or simvastatin (Zocor).	0.38 (0.49)	0.78	0.702
2. Risk factors	2. Examples of risk factors for heart disease that can be changed are blood pressure, cholesterol, smoking and secondhand smoking, waist size, and reaction to stress.	0.82 (0.39)	0.89	0.578	0.763	3.11 (1.25)	2.93–3.28
	12. To control blood pressure, one should lower the amount of sodium in the diet to less than 5 g/d, exercise, take blood pressure medication regularly (if prescribed), and learn relaxation techniques.	0.86 (0.35)	0.83	0.605
	16. To control cholesterol, one should become a vegetarian and avoid eggs.	0.78 (0.41)	0.91	0.587
	18. Diabetes cannot be prevented with exercise and healthy eating.	0.65 (0.48)	0.87	0.513
3. Exercise	4. The benefits of resistance training (lifting weights or using elastic bands) include increasing strength, improving the ability to carry out day-to-day activities, improving blood sugar levels, and increasing muscle mass.	0.63 (0.49)	0.91	0.597	0.782	2.65 (1.47)	2.43–2.84
	8. An exercise warm-up slowly increases heart rate and can lower the risk of developing angina.	0.68 (0.47)	0.85	0.619
	13. If someone gets chest discomfort during a walking exercise session, he/she should speed up to see whether the discomfort goes away.	0.69 (0.47)	0.80	0.606
	17. Someone knows whether he/she is exercising at the right level when the heart rate is in the target zone, the exertion level is no higher than “somewhat hard,” and he/she can exercise and talk at the same time.	0.65 (0.48)	0.79	0.529
4. Nutrition	5. Eating more meat and dairy products is a good way to add more fiber to one's diet.	0.68 (0.47)	0.86	0.504	0.742	3.23 (1.16)	3.06–3.38
	9. Prepared, processed foods usually have a high sodium content.	0.93 (0.26)	0.88	0.476
	14. Trans fats are partially hydrogenated vegetable oils (eg, vegetable shortening) and are unhealthy.	0.80 (0.40)	0.94	0.637
	20. A diet that can help lower blood pressure is rich in vegetables and fruits, whole grains, low-fat dairy, nuts, and seeds.	0.82 (0.38)	0.72	0.587
5. Psychosocial	7. The only effective strategy to manage stress is to avoid people who cause unpleasant feelings.	0.35 (0.48)	0.92	0.620	0.821	1.91 (1.57)	1.69–2.13
	10. Depression is common after a heart attack. Depression can lower one's energy level for rehabilitation and increases the risk of another heart attack.	0.54 (0.50)	0.83	0.678
	15. Sleep apnea that is not treated increases the risk for another heart attack, but it does not increase the risk of death.	0.38 (0.49)	0.78	0.699
	19. Stress is a large risk for heart attack and is as important as high blood pressure and diabetes.	0.63 (0.48)	0.82	0.580
Total	—	13.07 (4.57)	—	1	0.849	—	—

Maximum score for item is 1, and that for domain is 5. Based on N = 202, unless otherwise indicated.

Abbreviations: ASA, Acetylsalicylic acid; CI, confidence interval; ICC, intraclass correlation coefficient.

Test-retest reliability was high, with all intraclass correlation coefficients for all individual items greater than 0.70 (range, 0.72 [item 20] to 0.96 [item 1]) and most > 0.75 (good to excellent). There was good internal consistency with Cronbach α scores for the total score (0.85) and each domain (α > .7) (range, 0.74 [nutrition] to 0.82 [psychological]). Furthermore, the item total score correlations showed acceptable levels (>0.4) for each item (range, 0.40 [item 6] to 0.70 [item 11]).

Confirmatory factor analysis with maximum likelihood was conducted to examine the 5-factor structure. Several different indices were used to assess model fit (Supplementary File Figure S1, https://links.lww.com/JCN/A195). The modification indices indicated that further improvements were possible by including more covariance parameters (Tables 3 and 4). As the third model demonstrated acceptable estimates, it was determined that specifying these covariances for further model improvement was unnecessary (χ²/df = 1.39; comparative fit index, 0.958; GFI, 0.906; adjusted GFI, 0.872; root mean square error of approximation, 0.044; 95% confidence interval, 0.029–0.058). In addition, the standardized estimates (factor loading coefficients) of the model ranged from 0.30 (item 6) to 0.95 (item 3), and all were within the acceptable level (≥0.3) (Table 4). Hence, the 5-factor Chinese version of the CADE-Q SV was acceptable for the knowledge assessment of Chinese immigrants with CHD.

TABLE 3 - Confirmatory Factor Analysis Models With Specifications

No.	χ2	χ2/df	P	CFI, ≥0.90 to ≥0.95a,b	GFI ≥ 0.90a,b	AGFI ≥ 0.90a,b	RMSEA, ≤0.08 and ≤0.05c	Lower CI	Upper CI
1	254.67	1.62	<.001	0.931	0.890	0.853	0.056	0.043	0.068
2	234.06	1.51	<.001	0.944	0.899	0.863	0.050	0.037	0.063
3	212.93	1.39	.001	0.958	0.906	0.872	0.044	0.029	0.058
4	205.76	1.35	.002	0.962	0.911	0.877	0.042	0.026	0.056

Abbreviations: AGFI, adjusted goodness-of-fit index; CFI, comparative fit index; CI, confidence interval; GFI, goodness-of-fit index; RMSEA, root mean square error of approximation.

^aReference: Bentler PM, Bonett DG. Significance tests and goodness-of-fit in the analysis of covariance structures. Psychol Bull. 1980;88:588–606. http://dx.doi.org/10.1037/0033-2909.88.3.588

^bReference: Browne M, Cudeck R. Alternative ways of assessing model fit. In: Bollen KA, Long JS, eds. Testing Structural Equation Models. Sage Publications; 1993:136–162.

^cReference: Hu Lt, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Model Multidiscip J 1999;6(1):1–55.

TABLE 4 - Factor Loading From Confirmatory Factor Analysis

Domain	Item No. and Description	Unstandardized Estimate	Standard Error	P	Standardized Estimate
1. Medical	1. Coronary artery disease is a disease of the arteries in the heart that only happens in older people who have high cholesterol or smoke.	1.00			0.85
	3. “Angina” is chest pain or discomfort, at rest or during physical activity, which can be felt in the arm, back, and/or neck.	0.65	0.073	<.001	0.58
	6. Antiplatelet medications such as aspirin (ASA) are important because they lower the “stickiness” of platelets in the blood that blood flows more easily through the coronary arteries and past coronary stents.	0.34	0.080	<.001	0.30
	11. The “statin” medications limit how much cholesterol the body absorbs from food. Statin medications include atorvastatin (Lipitor), rosuvastatin (Crestor), or simvastatin (Zocor).	1.10	0.085	<.001	0.95
2. Risk factors	2. Examples of risk factors for heart disease that can be changed are blood pressure, cholesterol, smoking and secondhand smoking, waist size, and reaction to stress.	1.00			0.70
	12. To control blood pressure, one should lower the amount of sodium in the diet to less than 5 g/d, exercise, take blood pressure medication regularly (if prescribed), and learn relaxation techniques.	0.93	0.112	<.001	0.72
	16. To control cholesterol, one should become a vegetarian and avoid eggs.	1.03	0.130	<.001	0.68
	18. Diabetes cannot be prevented with exercise and healthy eating.	1.07	0.147	<.001	0.61
3. Exercise	4. The benefits of resistance training (lifting weights or using elastic bands) include increasing strength, improving the ability to carry out day-to-day activities, improving blood sugar levels, and increasing muscle mass.	1.00			0.69
	8. An exercise warm-up slowly increases heart rate and can lower the risk of developing angina.	1.03	0.125	<.001	0.73
	13. If someone gets chest discomfort during a walking exercise session, he/she should speed up to see whether the discomfort goes away.	0.85	0.119	<.001	0.60
	17. Someone knows whether he/she is exercising at the right level when the heart rate is in the target zone, the exertion level is no higher than “somewhat hard,” and he/she can exercise and talk at the same time.	1.00	0.123	<.001	0.71
4. Nutrition	5. Eating more meat and dairy products is a good way to add more fiber to one's diet.	1.00			0.57
	9. Prepared, processed foods usually have a high sodium content.	0.53	0.092	<.001	0.54
	14. Trans fats are partially hydrogenated vegetable oils (eg, vegetable shortening) and are unhealthy.	1.17	0.165	<.001	0.78
	20. A diet that can help lower blood pressure is rich in vegetables and fruits, whole grains, low-fat dairy, nuts, and seeds.	1.06	0.152	<.001	0.74
5. Psychosocial	7. The only effective strategy to manage stress is to avoid people who cause unpleasant feelings.	1.00			0.75
	10. Depression is common after a heart attack. Depression can lower one's energy level for rehabilitation and increases the risk of another heart attack.	0.96	0.106	<.001	0.69
	15. Sleep apnea that is not treated increases the risk for another heart attack, but it does not increase the risk of death.	1.19	0.119	<.001	0.87
	19. Stress is a large risk for heart attack and is as important as high blood pressure and diabetes.	0.76	0.104	<.001	0.56

Abbreviation: ASA, Acetylsalicylic acid.

Known-groups validation was demonstrated by a statistically significant difference in CHD knowledge scores between education levels (Table 5). Patients with an education level below tertiary reported lower CADE-Q SV scores compared with those with tertiary education and higher (11.53 [0.60] vs 14.16 [0.39], P < .001)). Similarly, English proficiency differed so that patients who did not speak English had lower knowledge scores than those who spoke English (12.02 [SD, 0.38] vs 13.66 [SD, 0.60], P = .017). Other variables were not statistically significant in the model, including age (P = .936), gender (P = .449), marital status (P = .474), working status (P = .844), duration of heart condition (<1 vs >5 years, P = .458; 1–5 vs >5 years, P = .891), cardiac rehabilitation attendance P = .992), and educational resources (P = .286). The normality assumptions assessed by the distribution of survey scores and the Q-Q plot of the residuals from the general linear model were plausible.

TABLE 5 - Discriminant Validity of the Short Version of Coronary Artery Disease Education Questionnaire (Simplified Chinese Version)

Variables	Na	Estimated Marginal Mean (SE)	B b	95% CI	P
Education level
Below tertiary	60	11.53 (0.60)	−2.63	−3.97 to −1.29	<.001
Tertiary and higher (ref)	137	14.16 (0.38)
English literacy
No	136	12.02 (0.38)	−1.64	−2.98 to −0.30	.017
Yes (ref)	61	13.66 (0.60)

Abbreviations: CI, confidence interval; ref, reference; SE, standard error.

^aN = 197 due to missing data in some characteristics (age, n = 3; education, n = 2).

^bModel adjusted for gender, marital status, working status, duration of heart condition, cardiac rehabilitation attendance, and educational resources.

Discussion

This study is the first to investigate the psychometric reliability and validity of the simplified Chinese version of the CADE-Q SV among an immigrant population and found acceptable psychometric properties for measuring CHD-related knowledge in Chinese immigrants. Specifically, Cronbach α coefficients and intraclass correlation coefficients indicated a good internal consistency and reliability level, respectively, and CFA indicated that the 5-factor model is acceptable for use in this patient group. Test-retest reliability has shown good consistency level of this instrument that it could be reliably applied to measure the knowledge levels at multiple time points before and after the educational intervention and for this particular patient population. Furthermore, this scale discriminated between known groups of patients with low education levels and poor English proficiency, which were associated with lower CHD knowledge scores. The CADE-Q SV (simplified Chinese version) is simple and free to use, takes less than 10 minutes for patients to complete, and can be used either paper based or online for CHD knowledge screening.

The CADE-Q SV has proven to be both adaptable and useful for multiple language groups; therefore, it is a good instrument to consider for further adaptation to other languages and, now, other immigrant populations.^24,49–51 Given the rapid growth of the Chinese and other immigrant populations in global migration, it is increasingly crucial that instruments be translated and validated in suitable samples, including language groups that have different backgrounds.^3,52 For example, in this study, we have recruited a group of Chinese immigrants living in the community from the metropolitan area of Sydney who originally came from different parts of China (and other related regions) with various socioeconomic statuses.

Interestingly, fluency in the host country's language is another critical factor to explore in terms of education and disease knowledge. In this study, sensitivity analysis has shown that lower education levels and poor English proficiency were associated with poor disease-related knowledge in Chinese immigrants with CHD. Similarly, previous studies have also indicated that language and cultural barriers, as well as inadequate health literacy, have impeded Chinese immigrants with CHD from accessing health-related information and reliable resources, particularly those aimed at promoting healthy lifestyles of nutrition and exercise.^6,7,25,52 Therefore, there is a need to use CADE-Q SV (simplified Chinese version) to understand their disease knowledge levels and improve their knowledge and healthy behaviors in clinical practice aligned with the delivery of culturally sensitive patient educational interventions.

Other cardiac knowledge instruments are available for patients with CHD, which have also been proven sensitive to change but do not assess knowledge broadly. For instance, the acute coronary syndrome Response Index (knowledge subscale) is widely adopted as a valid knowledge screening instrument in multiple educational intervention trials and has detected knowledge improvement in patients with CHD.^53–56 However, this scale was developed to assess delays in treatment-seeking and knowledge related to acute coronary syndrome symptoms only.⁵⁷ In comparison, the CADE-Q SV includes 5 domains of CHD-related knowledge, which involves a broader and more systematic understanding of CHD and its risk factors. Other valid instruments were also developed for CHD knowledge assessment, but most were developed explicitly for individual studies and not yet adapted to another language or immigrant populations.^58–61 Therefore, the CADE-Q SV is the first used in the Chinese immigrant population and has been tested to be suitable for use as a comprehensive CHD knowledge screening instrument.

Clinical implications regarding survey delivery and utilization related to survey use are essential.¹¹ Whereas previous CADE-Q SV validations were undertaken in acute care and cardiac rehabilitation centers, our study was the first to examine psychometric properties of the scale in various outpatient settings, including cardiologist clinics and other medical centers. The survey total score in the current sample is similar to reports of scores for the Chinese version, which was conducted in a sample in an acute care setting (13.07 ± 4.57 vs 13.15 ± 4.70).⁸ The brevity of time taken to complete the survey is essential in the clinical setting. We found that less than 10 minutes were required for survey completion, slightly longer than the English version but similar to the Chinese version elsewhere.^22,23 Furthermore, in this study, most surveys were completed in a digital version. Our results showed no statistical differences in mean scores between paper-based and digital surveys, and therefore, the survey is suitable for electronic assessment, which can increase the utility of the survey for preadmission or preclinic assessment. It is designed as a simple and short survey that should be asked to complete without assistance. Hence, it can provide healthcare providers with an overall understanding of their patients' knowledge base in terms of CHD knowledge and any score changes assessed at follow-up appointments.

The study findings need to be interpreted with caution. First, there is a lack of generalizability because participants were recruited from a single state in Australia; thus, a large cross-sectional study should be conducted. Second, a cutoff point has not yet been specified to determine how much disease knowledge is sufficient in this population group. Third, no trial has yet adopted this instrument for testing, so the sensitivity to change resulting from interventions remains uncertain. Furthermore, participants might have received educational resources at home or through the Internet to complete the survey, which contributes to the inaccuracy of their disease-related knowledge level. Finally, sociodemographic and clinical characteristics were self-reported, which may affect the true presentation of the patient group.

Conclusion

Overall, the simplified Chinese CADE-Q SV is a valid and reliable instrument and can be used in either paper-based or online form for disease knowledge screening in Chinese immigrants with CHD. The instrument is brief, free for use, and sensitive to education level and English literacy, which clinicians should consider when providing treatment and education to Chinese immigrants. Our reliability and validity test supports further testing of the CADE-Q SV in other languages and on other immigrant populations.

What’s New and Important

• The CADE-Q SV (simplified Chinese version) can be used as a valid and reliable instrument to evaluate the CHD-related knowledge of Chinese immigrants.
• This instrument is simple and free to use, takes less than 10 minutes for patients to complete, and can be used as either a paper-based or online screening instrument by health professionals.
• This scale discriminated between patients with low education levels and poor English proficiency, which were both associated with lower knowledge scores.