RELIABILITY AND VALIDITY OF THE MALAY VERSION OF BRIEF COPE SCALE: A STUDY ON MALAYSIAN WOMEN TREATED WITH ADJUVANT CHEMOTHERAPY FOR BREAST CANCER

Transcription

1 ORIGINAL PAPER RELIABILITY AND VALIDITY OF THE MALAY VERSION OF BRIEF COPE SCALE: A STUDY ON MALAYSIAN WOMEN TREATED WITH ADJUVANT CHEMOTHERAPY FOR BREAST CANCER N Yusoff1; WY Low2; CH Yip3 1. Women Health Development Unit, School of Medical Science, Health Campus, Science University of Malaysia, Kubang Kerian, Kelantan, Malaysia. 2. Medical Education and Research Development Unit, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. 3. Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. ABSTRACT This paper validates the Malay Version of Brief COPE Scale. Reliability was assessed using the test-retest method meanwhile internal consistency was indicated by the Cronbach s alpha value. Sensitivity of the scale was expressed as the mean differences (and the Effect Size Index) from the evaluation taken at two/three weeks and ten weeks following surgery. Discriminant validity was evaluated by comparing two groups of women i.e. mastectomy and lumpectomy. Internal consistencies ranged from 0.51 to In the meantime, the test-retest Intraclass Correlation Coefficient (ICC) ranged from <0.00 to Sensitivity of the scale was observed in nearly all of the domains with Effect Size Index (ESI) ranged from 0.00 to Significant differences between two groups of women (mastectomy and lumpectomy) were detected for Active coping, Planning, Positive Reframing, Religion and Self-distraction. Brief COPE Scale (Malay Version) confirms fairly good reliability and validity. Keywords: Cronbach s alpha, Malay Version, Brief COPE Scale, intraclass correlation coefficient, test-retest reliability and validity. Introduction Study on coping behavior among cancer patients has grown enormously and urge more attention for the specific population 1,2,3,4. Coping strategies refer to the specific efforts, both behavioral and psychological that people employ to master, 1

2 tolerate, reduce or minimize stressful events 5. Psychologist has pointed out that people use the strategies such as problem solving and emotion-focused to deal with stressful circumstances 6. The Brief COPE scale was proposed to assess a broad scope of coping behaviour among adults for all condition, illnesses or non-illnesses 7. The scale is rated by the four-point likert scale and comprises 28 items, ranging from I haven t been doing this at all (score one) to I have been doing this a lot (score four) 7. The higher score represents greater coping strategies used by the respondents 7. In total, 14 dimensions (two items for every dimension) are put forward by this scale 7. They are selfdistraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioural disengagement, venting, positive reframing, planning, humour, acceptance, religion and self-blame 7. Several dimensions of coping behaviour have been put forwarded by the earlier psychologist such as active coping, planning, seeking instrumental support etc 8. Active coping is the process of taking active steps to try to eliminate the stressor or to reorganize its effects 8. Meanwhile, the planning strategy is thinking about how to handle a stressor which engages with the action strategies, thinking about what steps to obtain and how best to cope with the problem 8. Seeking instrumental support is looking for advice, help or information 8. In the meantime, seeking emotional support is attainment of moral support, compassion or understanding 8. Behavioral disengagement is a dimension that reduces one s effort to deal with the stressor, even giving up the effort to accomplish objectives with which the stressor is interfering 8. Behavioural and mental disengagement apparently meaning in coping as they do in other province, such as test anxiety, social anxiety and in the selfregulation of behaviour more commonly 9,10,11. Another dimension such as denial, is a response that every so often appear in primary consideration, practical, lowering distress and in that way ease coping 12,13,14. Acceptance is a functional coping reaction whereby individual who acknowledge the reality of a stressful situation would employ in an effort to deal with the situation 8. Another important dimension i.e. religion is proposed in the scale as it serves as a source of emotional support 8. It is noted that one might turn to religion when under stress for varying reasons. The original report of Brief COPE Scale exhibited excellent internal consistencies for the dimension of Religion (α=0.82) and Substance Use (α=0.90) 7. Meanwhile, the same report displayed the acceptable values of Cronbach s alpha for some domains i.e. Active coping (α=0.68), Planning (α=0.73), Positive Reframing (α=0.64), Acceptance (α=0.57), Humor (α=0.73), Using Emotional Support (α=0.71), Using Instrumental Support (α=0.64), Self-distraction (α=0.71), Denial (α=0.54), Venting (α=0.50), Behavioral disengagement (α=0.65) and Self-blame (α=0.69) 7. Thus, this paper examines the reliability and validity of the Malay Version of Brief 2

3 COPE Scale applied on Malaysian women with breast cancer. Methods This study was carried out in three main hospitals in Klang Valley namely The University of Malaya Medical Centre (UMMC), The Kuala Lumpur General Hospital (KLGH) and The Hospital Universiti Kebangsaan Malaysia (HUKM), Kuala Lumpur. Ethical approval was obtained from these various institutions as well as from the Ministry of Health Malaysia. The study inclusion criteria were women who satisfied the following criteria: new cases of breast cancer, had undergone breast cancer surgery, were planned for adjuvant chemotherapy and had no current major diseases or chronic psychiatric condition. The translation of the original Brief COPE scale (English Language) into Malay Language was carried out based on the back translation technique proposed by Brislin (1970) and Koller et al. (2007). In this procedure, two Malay native speakers who were fluent English were used to do the Forward Translation which was English to Malay Language. Similarly, other two Malay native speakers who can speak and write English very well were employed to carry out the Backward Translation which was Malay to English Language. Women s feedback and comments on the difficulties in understanding or ambiguous meaning of certain words or sentences were recorded. The backward translation was reimplemented for the controversial words or sentences reported. The Malay Version of Brief COPE Scale were then pre-tested and finalized before it can be used for this study. The final Malay Version of Brief COPE Scale was distributed on the sample of women with breast cancer who were approached in the Oncology Clinics, where a list of eligible respondents was retrieved from the oncologist and breast surgeon (Coauthor). After the respondents were selected, they were briefed on the aim of the study. Before the questionnaires were distributed, the agreement of participation in the pilot study was obtained from the women with breast cancer, by getting a signature for the consent form. The information sheets for the patients followed the standard format taken from the Ethics Committee of the University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia, were also attached to the consent form. Two different phases of evaluation were undertaken in this study for the purpose of reliability and validity analyses. Firstly, prior-to chemotherapy i.e before women received the first cycle of chemotherapy, at approximately two to three weeks after surgery and; secondly, during chemotherapy i.e. after the third cycle of chemotherapy, at approximately ten weeks after surgery. Eligible women who agreed to take part in this study, completed the Malay Version of Brief COPE Scale themselves at clinic. Socio-demographic data was also gathered from the patients such as age, ethnicity, education, occupation, monthly income and duration of marriage. Medical information such as type of surgery, time since diagnosis 3

4 and stage of breast cancer were also obtained and recorded. Statistical Package of Social Science (SPSS) version 15.0 was utilized in data analyzing. Sixty eight of the women with breast cancer agreed to participate, and answered the Malay Version of Brief COPE Scale. The internal consistency of the Malay Version of Brief COPE Scale was assessed by calculating the Cronbach s alpha coefficient 15. Meanwhile, the test-retest reliability was assessed using the Intraclass Correlation Coefficient (ICC) which ranges from one (perfectly reliable) to zero 16. Sensitivity of the scale was determined by calculating the mean differences between the evaluation at phase one (prior-to chemotherapy) and phase two (during chemotherapy) of the study, by means of a paired t-test. The effect size of each domain of the Malay Version of Brief COPE scale was also reported 15. In addition, the ability of the scale to differentiate the coping strategies between women who had undergone mastectomy and women who had undergone lumpectomy (termed as discriminant validity), was also presented by the result of independent t-test. Results Table I presents the medical and bio/sociodemographic background of the respondents. The mean age of the women was 46.91±7.65 years old. The majority of the women had undergone mastectomy 53 (77.9%), as compared to lumpectomy 15 (22.1%). Majority of them were diagnosed with stage two of breast cancer (54.4%, n=37), followed by stage three (38.2%; n=26) and stage one (7.4%, n=5). The time of diagnosis to their participation in the study was a mean of (sd±2.47) days. With regards to menopausal status, majority of these women were pre-menopausal (61.8%, n=42), followed by the postmenopausal (30.9%, n=21) and the perimenopausal (7.4%, n=5) group. These women had at least a secondary education (64.7%, n=44), with a household monthly income of at least RM3000 or USD (80.9%, n=55). Most of the women were unemployed or housewives (58.8%, n=40). Table I: Bio/socio-demographic and Medical Characteristics of the Women with Breast Cancer (N=68) Age (mean ± sd) 46.91±7.65 years Education Levels: Primary school 10 (15%) Lower secondary 20 (29.4%) Upper secondary 24 (35.3%) Form 6/Diploma/Certificate 13 (19.1%) Tertiary 1 (1.5%) Household Monthly Income (RM3.80=USD1): Less than RM (25.0%) RM1001 to RM (55.9%) RM3001 to RM (8.8%) More than RM (10.3%) 4

5 Occupation: Professionals 7 (10.3%) Technicians and associate professionals 5 (7.4%) Clerical workers 11 (16.2%) Service workers/shop market sales workers 4 (5.9%) Housewives 40 (58.8%) Pensioner 1 (1.5%) Types of Breast Cancer Surgery: Mastectomy 53 (77.9%) Lumpectomy 15 (22.1%) Menopausal Status: Pre-menopausal 42 (61.8%) Peri-menopausal 5 (7.4%) Post-menopausal 21 (30.9%) Stages of Breast Cancer: Stage 1 5 (7.4%) Stage 2a 21 (30.9%) Stage 2b 16 (23.5%) Stage 3a 16 (23.5%) Stage 3b 7 (10.3%) Stage 3c 3 (4.4%) Duration of Breast Cancer (mean ± sd) (From diagnosis to their participation in the study) 52.04±2.47 days Table II shows the internal consistency, Intraclass Correlation Coefficient, sensitivity and discriminant validity of the scale. The internal consistency indicated by the Cronbach s alpha values ranged from 0.51 to Meanwhile, the test-retest Intraclass Correlation Coefficient (ICC) ranged from <0.00 to Sensitivity of the scale was indicated by the mean differences as observed in most of the domains i.e. Active Coping (p<0.001), Planning (p<0.05), Positive Reframing (p<0.001), Religion (p<0.05), Using Emotional Support (p<0.01), Using Instrumental Support (p<0.05), Denial (p<0.05), Venting (p<0.05) and Self-blame (p<0.01). In the meantime, Effect Size Index (ESI) ranged from 0.00 to In the analysis of discriminant validity, the significant p-value was observed for Active coping (p<0.01), Planning (p<0.01), Positive Reframing (p<0.05), Religion (p<0.05) and Selfdistraction (p<0.05), indicating the ability of the scale to detect the differences of these coping strategies between women who had been treated with mastectomy and women who had been treated with lumpectomy. 5

6 Table II: The Reliability and Validity of the Malay Version of the Brief COPE Scale (N=68) Phase 1 Evaluation Mean (SD) Phase 2 Evaluation Mean (SD) Test-retest (ICC) Internal consistency (Cronbach s alpha) Sensitivity to change Mean differences (ESI) Discriminant Validity 1 Brief COPE: Active 5.82 (±1.47) 7.32 (±1.11) < (0.49)*** p=0.002 coping Planning 5.81 (±1.49) 6.35 (±1.31) (0.19)* p=0.008 Positive 5.13 (±1.33) 6.57 (±1.36) (0.48)*** p=0.034 reframing Acceptance 6.82 (±1.27) 6.81 (±1.30) (0.01) NS Humour 3.35 (±1.51) 3.35 (±1.89) < (0.01) NS Religion 7.04 (±1.27) 7.51 (±0.70) (0.21)** p=0.028 Using 5.31 (±1.37) 6.01 (±1.80) (0.21)** NS emotional support Using 5.62 (±1.66) 6.40 (±1.60) (0.22)** NS instrumental support Selfdistraction 5.90 (±1.50) 6.15 (±1.35) (0.09) p=0.011 Denial 5.78 (±1.46) 6.04 (±1.59) (0.04)* NS Venting 5.93 (±1.59) 2.24 (±1.12) (0.04)* NS Substance 2.22 (±0.99) 4.54 (±1.08) (0.01) NS use Behavioural 4.56 (±1.05) 4.63 (±1.11) (0.01) NS disengagem ent Self-blame 5.13 (±1.28) 5.31 (±1.51) (0.06)** NS ***p<0.001; **p<0.01; *p<0.05 Phase 1 = Two/three weeks following surgery; Phase 2 = Ten weeks following surgery ICC = Intraclass Correlation Coefficient ESI = Effect Size Index 1. Discriminant validity of the scale was calculated by comparing two groups of women i.e. women with mastectomy and women with lumpectomy. Discussion Most of domains of the Malay Version of the Brief COPE Scale indicated fair internal consistencies. This finding could be recognized as most of the subscales in the original Brief COPE scale also presented fairly internal consistencies with Cronbach s alpha value which was less than Domains such as Acceptance (0.98), Denial (0.96), Venting (0.95), Behavioural Disengagement (0.96), Substance Use (0.59) and Self-blame (0.93), suggesting an excellent agreement as compared to Active coping (<0.00), Planning (0.06), Positive Reframing (0.10), Humour (<0.00), Religion 6

7 (0.11), Using Emotional Support (0.18), Using Instrumental Support (0.27), Selfdistraction (0.06) showed poor ICC values, which showed low agreement between the evaluation done at prior-to and during chemotherapy phases. This could probably be due to the fact that the coping strategies which were based on the element of action were influenced by the phases of the treatment (pre- and during chemotherapy), while the coping strategies which were based on the element of psychology were found to be the contradictory. The Malay Version of Brief COPE scale showed a range of effect size, from trivial to moderate (0.00 to 0.49), which illustrates that the effect of treatment phases on women s coping strategies is associated with the nature of the coping behaviour itself, when dealing with the life crisis. Variations in the sensitivity of the scale was perhaps due to the treatment situation measured prior-to and during chemotherapy phases, and not because of the low sensitivity of the scale to detect a change. It was observed that the Malay Version of Brief COPE Scale discriminated the strategies of Active coping, Planning and Positive Reframing between the groups of women who had undergone mastectomy and women who had undergone lumpectomy. Nevertheless, no differences were observed between the mastectomy and lumpectomy groups in other domains, which is in lieu with some previous findings 17,18. This could mean that the psychosocial aspect between women who had mastectomy and women who had lumpectomy were almost similar. In conclusion, the Malay Version of Brief COPE Scale is a reliable and valid instrument which could be applied for the Malaysian population, with regards on its acceptable internal consistency and the ability of the scale to detect the changes as indicated by the mean differences and the value of Effect Size Index (ESI). Nonetheless, the low values of Intraclass Correlation Coefficient (ICC) and a small sensitivity of some of the domains could be due to the different treatment phases and the nature of the coping behavior itself. In addition, findings from previous studies should also be referred to in order to support and justify the current finding of the study 7, 17. Acknowledgements Special acknowledgements are dedicated to University of Malaya (UM), Kuala Lumpur, Malaysia, for the financial support (Fundamental Grant: FP058/2005C) and to all the women with breast cancer who had willingly taken part in this study. References 1. Link LB, Robbins L, Mancuso CA and Charlson ME. How do cancer patients choose their coping strategies? A qualitative study. Patient Education and Counseling 2005; 58: Li J and Lambert VA. Coping strategies and predictors of general wellbeing in women with breast cancer in the People's Republic of China. Nursing and Health Sciences 2007; 9 (3): Anagnostopoulos F, Vaslamatzis G and Markidis M. Coping strategies of 7

8 women with breast cancer: A comparison of patients with healthy and benign controls. Psychotherapy and Psychosomatics 2004; 73 (1): Barez, M., Blasco, T., Fernandez- Castro, J. and Viladrich, C. A structural model of the relationships between perceived control and adaptation to illness in women with breast cancer. Journal of Psychosocial Oncology 2007; 25 (1): John D and MacArthur CT. Research Network on Socioeconomic Status and Health [Online] 1998; Available at: chosocial/n ial/notebook/coping.html. [Assessed 19 March 2008] 6. Folkman S and Lazarus RS. An analysis of coping in a middle-aged community sample. Journal of Health and Social Behavior 1980; 21: Carver CS. You want to measure coping but your protocol s too long. Consider the Brief COPE. International Journal of Behavioral Medicine 1997; 4 (1): Carver CS, Scheier MF and Weintraub JK. Assessing Coping Strategies: A Theoretically Based Approach. Journal of Personality and Social Psychology 1989; 56 (2): Carver CS and Scheier MF. A control-theory model of normal behavior, and implications for problems in selfmanagement. In Kendall PC, ed. Advances in Cognitive-behavioral Research and Therapy. New York: Academic Press, 1974: Carver CS and Scheier MF. Analyzing shyness: A specific application of broader self-regulatory principles. In Jones WH, Cheek JM and Briggs SR, eds. Shyness: Perspectives on Research and Treatment. New York: Plenum Press, 1986: Scheier MF and Carver CS. A model of behavioral self-regulation: Translating intention into action. In Berkowitz L, ed. Advances in Experimental Social Psychology, New York: Academic Press, 1988; Breznitz S (ed). The Denial of Stress. New York: International Universities Press, Cohen F and Lazarus RS. Active coping process, coping dispositions and recovery from surgery. Psychosomatic Medicine 1973; 35: Wilson JF. Behavioural preparation for surgery: Benefit or harm? Journal of Behavioral Medicine 1981; 4: Cohen, J. Statistical power analysis for the behavioral analysis. Academic Press: New York, Deyo RA, Dichr P and Patrick DL. Reproducibility and responsiveness of health status measures. Control. Clin. Trials 1991; 12 (Suppl.1): Buddeberg C, Riehl-Emde A, Landont-Ritter C et al. The significance of psychosocial factors for the course of breast cancer-results of a prospective follow-up study. Schweizerische Archive Neurology Psychiatry 1990; 141 (5):

9 Corresponding address: Dr Nasir Yusoff, Women Health Development Unit, School of Medical Science, Health Campus, Science University of Malaysia, Kubang Kerian, Kelantan, Malaysia. Tel: Fax: address: or 9