Validity and reliability of the Persian version of the Coping Assessment for Bereavement and Loss Experiences (CABLE)

doi:10.21203/rs.3.rs-1511130/v1

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Validity and reliability of the Persian version of the Coping Assessment for Bereavement and Loss Experiences (CABLE)

https://doi.org/10.21203/rs.3.rs-1511130/v1

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Background and Aim:

The loss of loved ones following death, although very sad, becomes an inexperience for every person. Some people are very disabling and threatening to mourn. One of the factors that may distinguish people in response to grief is the coping strategies to deal with grief. The result of this study was designed to translate and determine the characteristics of psychological tools to assess coping with the experiences of grief and loss (28 items) in people living in Tehran, Iran.

Materials and Methods

This is a methodological study with a descriptive cross-sectional design that after obtaining written permission from the original developer and according to the WHO protocol, the Persian version of the questionnaire was completed by 480 experienced mourners living in Tehran in February 2021 to October 2021. Then, the Face validity, Content validity and Construct validity of questionnaire were assessed. Cronbach's alpha coefficient and Test-retest were used to determine the reliability.

Results

Cronbach's alpha for all items was 0.91 and intraclass correlation coefficient was 0.86, both of which indicate the reliability of the Persian version of the CABLE tool. Based on the maximum likelihood exploratory factor analysis and confirmatory factor analysis six factors were identified. The factors could explain 50% of the total variance observed. The model had an acceptable fit: GFI: 0.88, CFI: 0.96, IFI: 0.96, NFI: 0.92, PNFI: 0.82, RAMSEA: 0.058, CMIN/DF: 2.37 RMR: 0.056. Internal consistency and construct validity of the questionnaire were confirmed.

Conclusion

The findings of the present study indicate that the Persian version of CABLE is a tool with appropriate validity and reliability that can be used as a native tool to assess compliance with the experiences of grief and loss.

Coping

Grief

psychometrics

Persian

Mourning is a universal human phenomenon [1, 2], an inevitable experience [3, 4], very personal and multidimensional in the life of each person and has pervasive effects on the bereaved person [4]. More precisely, the mental feeling caused by the death of a loved one is called mourning [2, 5], while mourning refers to the process of dissolving mourning [6].Also in Dehkhoda dictionary, mourning has been interpreted and equated with the concept of misery, grief and mourning (following the death and loss of loved ones) [7]. The common point of all texts in defining the concept of mourning, the loss of a valuable being (human, commodity, position, peace, belief [8]. Man as a social being, creates deep attachment bonds and after breaking these bonds by Separation and loss due to death tend to mourn [9]. All groups, from the smallest unit, which is the family, to the whole community, have a normative framework called culture, which is dominated by the behaviors of individuals and how rituals are performed and how they are performed (culture). Inspired [10]. One of these behavioral acts is grief. We all belong to social groups that have internalized the prevailing norms for how to grieve [11]. On the other hand, in many studies, religion, religion and spiritual approach are considered important and effective in how to deal with the experience of loss and mourning and the way of mourning [12]. It is clearly reported that religiosity and religion and ritual behavior are very effective during the period of mourning [13]. The prevalence of grief and its consequences vary due to differences in social norms and cultural expectations [3,14]. Defining the stages, duration, and complexities of grief is not only difficult because of individual and cultural differences, but the prevalence of the disorder is not the same in different societies and cultures [15, 16]. In the meantime, concepts such as crisis, following the loss of resources and benefits (lives, property and loved ones ...) predict mourning according to its multidimensional nature [17, 18]. As a global crisis, with the outbreak in the first half of 2020, Covid 19 drastically changed human relations, norms, and the quality of experiences of loss and grief at the population level [19]. It is predicted that societies will face very important and dangerous periods in this crisis due to depression, anxiety and post-traumatic stress caused by grief and the experience of loss [4, 19]. In most cases, the period of mourning is naturally accepted and spent by the bereaved as a fact of life [20], but not all people adapt in a style to the experience of loss, and among these, 10–15% of the bereaved and mourning population show an incapacitated and life-threatening reaction known as complex mourning [21]. One of the factors that may differentiate people's reactions to grief is how they adapt and coping to the experience of absence [22]. Identifying adaptive coping strategies and practices is very important and necessary for mental health professionals to intervene to support the grief and injury caused by bereavement and loss [23]. However, one of the barriers to grief coping and the experience of loss is the lack of specific tools related to the concept of grief to evaluate potentially constructive coping strategies for grief coping. In 2017, Crunk et al, Designed a dedicated tool for bereavement coping and experience of loss, and is currently the only 28-item CABLE dedicated tool. Therefore, in this study, the ability to use specific CABLE tools to assess coping with bereavement and the experience of loss in Iranian society and culture, with the aim of translating and determining psychometric properties, was examined.

Ethical considerations

The objectives of the study were explained to the participants. All of them were provided with the necessary explanations in the attachment sheet of the virtual questionnaire regarding the confidentiality of their information with the researchers. This study was conducted in accordance with the Helsinki Declaration.

Participants

The sample of this study includes all people over 18 years of age with a history of grief experience that is at least 6 months old. The questionnaire was made available to individuals virtually through social networks. The sample size in this study was 300 people. This is 10 times the number of tool items. The questionnaire was provided to the participants electronically and in person, and finally 480 questionnaires were completed and delivered.

The Coping Assessment for Bereavement and Loss Experiences (CABLE)

CABLE is a scale designed to identify coping strategies that mourners use to cope with Bereavement and loss. This scale consists of 28 items that are followed by convergent validity in the original version of CABLE with the Brief Cope scale. And is set in 6 areas: Help Seeking (7 items), Positive Outlook (5 items), Spiritual Support (4 items), Continuing Bound (5 items), Compassion Outreach (3 items), Social Support (4 items) and its response On a scale of 6 to zero (I have never done this), (I have done this once), (I have done this many times), (I do it almost daily I have done this, (I have done this every day), (this does not apply to my menu and my mourning). Cronbach's alpha coefficient of the total scale was 0.91[23,24].

Study design

The present study is a methodological research that has been conducted with the aim of translating and psychometric evaluation of the Persian version of the questionnaire to assess compliance with grief and the experience of loss from April 2020 to April 2021 in the form of a cross-sectional descriptive design.

Validity and Reliability

The translation is performed according to the standard defined in the validity of the instrument by the World Health Organization. After obtaining written permission from the original designer of the "CABLE" tool, using the World Health Organization guide and the Forward method, the translation process began [25, 26]. In the first stage, the "CABLE" questionnaire was translated into Persian by three translators whose mother tongue was Persian and who had sufficient experience and proficiency in translating English texts. During the translation, an attempt was made not to change the meaning and concept of the phrases and their level of difficulty. In this regard, in the translation process, the conceptual equivalence of words, sentences and phrases was emphasized. In the second stage, the original translated versions were reviewed and compared by experts, and the discrepancies between them were corrected and the original translations were merged. Then, in the third stage, the translated version was independently translated into English by two fluent English speakers (a Canadian Citizen Doctor and a skilled English translator), and then an agreed-upon version was reviewed, and finally the final English version. Prepared with the original version to receive approval for the original design and after applying his comments and suggestions, the final approval was received.

Face and content validity

Cognitive interviews were used to perform face validity. The Persian version of the scale was provided to 15 people with experience of mourning, over 18 years of age with a minimum level of literacy, and qualitative face validity was performed. Due to the existing cultural-socio-religious differences, limited changes were made in some words. Then, in reviewing the quality validity of the content, 10 experts (respected university professors with experience in methodology, psychometrics, instrumentation, psychology and nursing) in this field were asked to review the quality of the scale based on grammar criteria. Use the right words, place the items in the right place, and score the right amount to provide the necessary feedback [27, 28].

Item analysis

At this stage, the final and modified version of the scale was given to 30 participants. Using SPSS 26 software and loop technique, the correlation between items and the correlation of each item with the total score were measured. Cronbach's alpha was also described after removing each item.

Construct validity

Exploratory factor analysis was used to determine the Construct validity. In this method, Kaiser-Meyer-Olkin test (KMO) was used to evaluate the adequacy of sampling. (KMO <0.7) Measurement of KMO close to 1 indicates developmental adequacy. High negation in factor analysis and KMO between 0.7-0.8 and above 0.8 is considered good. Then the correlation matrix between the variables was evaluated using Bartlett test for factor analysis with an error level of less than 0.05. To extract the factors, the Principal axis factoring (PAF) and Scree design were used. Also, the rotation of factors in this study was done by rotation of Promax. Data analysis in EFA was performed using Spss 26 software.

For confirmatory factor analysis, 220 individuals were surveyed according to inclusion criteria and by sampling method. In confirmatory factor analysis, several change techniques were used to evaluate the relationships. In order to fit the model, chi-square, chi-square to degrees of degree of error scales, goodness-fit index, standardized fit index, and adaptive fit index are used, which are commonly used in determining fit in factor analysis. In examining the goodness indicators of fit, if the result of the chi-square test is not statistically significant, the fit of the model indicates. The first degree error criteria show the fit for each of the freedoms, and the closer the model is to the greater zero of the model. If the square root of the error is less than 0.08, it indicates a very good fit, 0.08 to 0.1 indicates an acceptable fit, and greater than 0.1 indicates a poor fit of the model. Goodness indicators of fit, handled fit and adaptive fit are indicators that have been developed to compare the model and are calculated with a base model. Their online is between zero and 1 and above 0.9 indicates a good fit of the model [29]. Data analysis in CFA was performed using Lisrel 8.8 software.

Reliability

Reliability was assessed by two methods of internal consistency including Cronbach's alpha and test-retest. In the open test phase, the scale was given to 30 subjects in two stages two weeks apart. Then the intraclass correlation coefficient (ICC) was calculated with a confidence interval of 0.95 and values above 0.7 were accepted for scale stability.

Samples

The mean age of participants in this study was 18–86 years, of which 56.6% were women. 15.3% of them in the last 6 months, 17.3% in 6 months to 1 year, 29.4% in 1–5 years and 38% of them have more than 5 years of experience of grief and loss.

Face and content validity

After review by respected faculty members and experts, some cases were changed and adjusted due to religious-cultural differences. For example, in question 13, instead of the Bible and prayer, the Qur'an, texts and prayers were used, and in question 16, in addition to the synagogue and the church as religious places, the mosque was also mentioned. In other cases, there was no cultural difference and simpler and similar expressions were used. In content validity, semantic convergence, comprehension, clarity and difficulty of the items were evaluated. The scale was considered appropriate by content validation experts.

Item analysis

The correlation between cases was 0.26 to 0.54. The highest correlation is related to case 14 and the lowest correlation is related to case 2. The results are presented in Table 1.

Table 1

Item-Total Statistics
	Corrected Item-Total Correlation	Cronbach's Alpha if Item Deleted
CABLE-1.	.365	.884
CABLE-2.	.264	.886
CABLE-3.	.318	.885
CABLE-4.	.376	.884
CABLE-5.	.387	.884
CABLE-6	.447	.882
CABLE-7	.371	.884
CABLE-8.	.388	.883
CABLE-9	.536	.880
CABLE-10	.522	.880
CABLE-11.	.527	.881
CABLE-12.	.503	.881
CABLE-13.	.456	.882
CABLE-14.	.548	.880
CABLE-15.	.529	.880
CABLE-16.	.413	.883
CABLE-17.	.416	.883
CABLE-18.	.465	.882
CABLE-19.	.487	.881
CABLE-20.	.297	.886
CABLE-21.	.495	.881
CABLE-22	.526	.880
CABLE-23.	.432	.882
CABLE-24	.537	.880
CABLE-25.	.491	.881
CABLE-26	.362	.884
CABLE-27	.420	.883
CABLE-28.	.416	.883

Construct validity

To ensure the suitability of the data for factor analysis, the KMO test was calculated to be 0.871. Bartlett test with respect to < 0.001) (p was significant = 4511.146) (X2. In addition, PROMAX rotation method was used to extract factors and evaluate the validity of the structure. As a result, six factors with eigenvalues greater than 1 It was found that the cumulative variance explaining the concept by the instrument is 50% and acceptable. The results are presented in Table 2 and Fig. 1.

The results of confirmatory factor analysis also provided a good estimate based on the general fit indices of the model. The results are presented in Table 3. According to the final model of the factor structure of the CABLE structure, the variables showed a high correlation with their respective factor. The results are presented in Fig. 2

Table 2

Exploratory Factor Analysis of the Farsi Version of the CABLE
Factor	Items	% of Variance	α	ICC
Factor1	q10	23.816	0.894	0.848
	q9
	q8
	q12
	q11
	q19
	q18
Factor2	q16	8.496	0.822	0.894
	q17
	q20
	q13
	q21
Factor3	q6	6.117	0.928	0.911
	q24
	q25
	q7
Factor4	q22	5.365	0.870	0.843
	q14
	q23
	q15
	q28
Factor5	q3	3.096	0.685	0.831
	q5
	q4
Factor6	q1	2.434	0.764	0.792
	q27
	q26
	q2
Cumulative %		49.324	0.910	0.862

Table 3

Values of fitting indices of CABLE tool confirmatory factor analysis pattern
Result	Fit Index
05/0<	P-value 2_X (Chi-squared P-value)
335	Degrees of Freedom
800.68	Normal Theory Weighted Least Squares Chi-Square
0.058	RMSEA
2.37	CMIN/DF
0.92	NFI
0.96	CFI
0.88	GFI

Reliability

In this study, the scale has an overall alpha coefficient of 0.910. Cronbach's alpha was 0.894 for the first factor, 0.822 for the second factor, 0.928 for the third factor, 0.870 for the fourth factor, 0.685 for the fifth factor and 0.764 for the sixth factor. Also, in measuring the test stability by retesting method and using interclass correlation coefficient (ICC) with 95% confidence interval, the total ICC value is 0.862. ICC first factor is 0.848, second factor is 0.894, third factor is 0.911, fourth factor is 0.843, fifth factor is 0.831 and sixth factor is 0.792.

The results of this study showed that CABLE has good credibility and reliability among people with experience of grief and loss in Iran and can be a good criterion for evaluating coping strategies in grief and loss. In the present study, the KMO value is equal to 0.871. This rate is reported to be 0.883 in the study of Crank et al., Who are the main designers of this tool. In the exploratory factor analysis, six factors were identified by the Promax rotation method, which corresponds to the number of factors identified in the study of Crank et al[23,24].

The eigenvalues in the study of Crank et al[23,24] were 8.4 and explained 57.81% of the variance, and the eigenvalues in the current study are 7.2, which explains 50% of the variance. To evaluate the internal consistency of the instrument, Cronbach's alpha reliability coefficient was used, which is equal to 0.91, which is reported to be 0.89 in the study of Crank et al[23,24]. In both studies, the subsurface Compassionate Outreach factor is acceptable (in Crank et al.'s study equal to 0.66 and in the current study 0.68 but due to the fulfillment of all pre-determined psychometric criteria in each two studies have been preserved. In the study of Crank et al[23,24]. The correlation between the items in the correlation matrix is from 0.00 to -0.3 and in the current study it is from 0.4 to 0.8. A review of the literature shows that the minimum acceptable value for the correlation between items is 0.15. Therefore; The correlation of all items is appropriate. In the study of Crank et al .; The results of confirmatory factor analysis of the items are as follows: RMSEA = 048/0 CFI = 924/0 NFI = 81/0 RMR = 078/0 And these indicators in the current study are as follows: RMSEA = 058/0 CFI = 96/0 NFI = 92/0 0 RMR = 056/0 As can be seen in the literature review, CABLE was first designed and psychoanalyzed in 2017 by Crank et al[23,24] and the results of the current study are somewhat similar to the results and findings of the original designers, indicating that all human beings with different cultures and religions need to adapt to stress in order to survive. There are various types of mourning for loved ones that based on contemporary models of adaptation to mourning (dual process model and meaning reconstruction model), people without the choice between two ends of a continuum to look for coping strategies to alleviate grief and accept new conditions. There are many similarities between adults with the experience of grief in different cultures, which may be related to the globalization of culture.

Based on the findings, CABLE has good credibility and reliability in Iran and can be used to evaluate the coping strategies of adults in mourning for the purposes of psychological research, sociology or cultural policy.

This study was performed on adults living in Tehran and often electronically. It is suggested that this study be performed in person in adults living in other cities with cultural diversity and in person.

Acknowledgments

Researchers consider it necessary to thank the panel of experts who contributed to the translation of the scale, and The authors and facilitators of the project would like to express their gratitude to Ms. Elizabeth Crank, the original designer of the questionnaire, for agreeing to provide the CABLE psychometric license in Iran and to all those who participated in completing and collecting the questionnaires.

Authors’ contributions

AE, was responsible for the study design, supervised the study, led the analysis plan, conducted the data analysis, interpreted the findings and revised the manuscript. AS, led the data collection, contacted experts to translate the CABLE and drafted the manuscript. MFf, confirmed and modified the translated version of CABLE . HSHn, monitored the data structure input and output before analysis. All authors read and approved the final manuscript.

Funding

This study was conducted with the financial support of Tehran Islamic Azad University of Medical Sciences, so the researchers are grateful to this university. The funding University did not have any role in the design of the study, the collection, analysis, and interpretation of the data, or the writing of the manuscript.

Availability of data and materials

The datasets generated and/or analyzed during the current study are available from first and Corresponding author of this article upon reasonable request.

Ethics approval and consent to participate

Informed written consent was obtained from all participants. The present study with the code IR.IAU.TMU.REC.1400.316 approved by ethics committee of Scholl of Nursing and Midwifery of Tehran Islamic Azad University of Medical Sciences.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests to disclose.

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No competing interests reported.

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You are reading this latest preprint version

Validity and reliability of the Persian version of the Coping Assessment for Bereavement and Loss Experiences (CABLE)

Status:

Version 1

Abstract

Background and Aim:

Materials and Methods

Results

Conclusion

Figures

Introduction

Methods

Results

Samples

Face and content validity

Item analysis

Construct validity

Reliability

Discussion

Conclusion

Limitations

Declarations

References

Additional Declarations

Status:

Version 1