The Validity of the Smart Management Strategy for Health Assessment Tool-Life (SAT-Life) in General Population

This study aimed to determine the reliability and validity of the life version of the Smart Management Strategy for Health Assessment Tool (SAT-Life) for the general South Korean population. We recruited 1,200 respondents using an equal-probability sampling method from March to May 2018. A life version of the Smart Management Strategy for Health Assessment Tool (SAT-Life) Cronbach’ α was used to determine the reliability of the 30-item SAT-Life. Comparisons with the Self-Reported Health Status (SRHS), Short Form-12 (SF-12), McGill Quality of Life Questionnaire (MQOL), Patient Health Questionnaire-9 (PHQ-9), and Satisfaction with Life Scale (SWLS) were conducted for establishing the discriminant and concurrent validity. Three sets of SAT-Life demonstrated a high reliability with good internal consistency (Cronbach’ α 0.86 for SAT-Core, 0.88 for SAT-Preparation, and 0.86 for SAT-Implementation). The total scores of the three SAT differentiated well between the before-maintenance group versus the maintenance group for achieving goals in the participants, and between the group with high depression score versus that with lower depression score in the general population. These SAT-Life scores were positively associated with health status and physical and mental quality of life (QOL). The scores of the SAT-Life were correlated with social support and spiritual well-being measured using the MQOL, and life satisfaction measured using SWLS. The 30-item SAT-Life had a satisfactory internal consistency and validity for the general South Korean population. Further validation should be carried out in a cohort study across different cultures, including an assessment of sensitivity.


Introduction
Most people experience life crises infrequently and may face the stresses such as death of a spouse or child, divorce, imprisonment, personal illness, marital con icts, and dismissal from work. ( assessing coping strategies, such as Seven Habit Pro les, (Covey 2004) Brief COPE (Carver 1997) and Post-Traumatic Growth Inventory (PTGI) (Tedeschi and Calhoun 1996).
In previous studies, we developed the Smart Management Strategy for Health Assessment Tool (SAT) (Yun et al. 2015), which evaluates the patient's time-speci c strategies based on the conceptual frameworks of management strategy for health support of individuals overcoming the crisis and promoting their positive growth. Moreover, to reduce the assessment burden and elicit comprehensive information about the patient's strategies, we developed a 30-item short version of the SAT. (Yun et al. 2018b) The SAT-SF demonstrated good internal consistency and promising reliability compared to the original form. (Yun et al. 2018b) Therefore, in this study, we aimed to modify the SAT-SF to assess coping strategies for overcoming life crises and improving QOL and well-being among the general population, validate the assessment tool with the general population, and rename it as the Smart Management Strategy for Health Assessment Tool-Life version (SAT-Life).

Study Design and Subject Recruitment
Data were collected from a broader general population targeted in the survey. Firstly, the survey was conducted with the general population aged 20-70 years and residing across 17 major cities and local districts from March to May 2018. In each major city and local district, all participants were recruited using two strata (age and sex) following the guidelines of the 2016 census of Korea. We used a probability-proportional-to-size technique for sample selection to represent a nationwide sample.(Paul S. Levy 2013) As the response rate was expected to be 30%, approximately 4,000 people were contacted over the 17 major cities and local districts. Finally, 1,200 of them agreed to respond to the survey.
The survey data were collected by skilled interviewers of World Research Co. Ltd., professionalized in conducting surveys in Korea, who explained the purpose and details of the questionnaire to the respondents. All recruiters provided informed consent. The research procedures followed the tenets of the Declaration of Helsinki and were approved by the Institutional Review Board of Seoul National University College of Medicine (IRB No: 1804-024-934).

Measurements
To assess the validity and sensitivity of the SAT-Life among the general population, all the participants answered the questionnaire starting with socio-demographic characteristics including age, sex, marital status, income, educational level, residential area, religion, and employment status.

Statistical Analysis
Firstly, to test the reliability of the SAT-Life, we estimated Cronbach's α, which is a measure of internal consistency of patient responses. In general, α ≥ 0.70 was considered appropriate for the aggregation of responses into a single score. (Elvén et al. 2018) Secondly, descriptive statistical analysis was conducted for demographic characteristics of respondents. Third, to assess discriminant validity, we analyzed the general population with high competency in the SAT-Life scores (SAT-C, SAT-P, and SAT-I) under the hypothesis that they would perform better in goal practice, health status, and QOL, and show lower depression. We calculated each of SAT-C, SAT-P, and SAT-I strategy differentiation according to the participants' socio-demographic variables, goal practice level, ve health statuses, physical and mental component summary from SF-12, and depression level on PHQ-9 to determine the validity of SAT-Life for use with the general population. To assess associations between them, univariate logistic analysis was performed to produce odds ratios (ORs). Each SAT-Life score, less than or equal to 66.6, was set as a reference point for comparisons between groups with higher SAT-Life scores on SAT-C, SAT-P, and SAT-I. (Fayers et al. 1995) Finally, to assess concurrent validity, correlation analyses between SAT-Life, MQOL, and SWLS scores in the general population were conducted. All calculated p-values were two-sided with the signi cance level set at p < 0.05. SAS statistical package version 9.3 (SAS Institute, Cary, NC, 1990) and R 3.5.1 were used for all analyses.

Results
The characteristics of the study participants are summarized in

Reliability of SAT-Life
Each of the three SAT-Life sets was applied into cross-validation of the newly enrolled general population sample. All values on the three SAT-Life sets showed a high reliability with good internal consistency (Cronbach's α: 0.860 for SAT-C, 0.880 for SAT-P, and 0.860 for SAT-I) (  Abbreviations: Fac, Factor; SAT-C, SAT-Core; SAT-P, SAT-Preparation; SAT-I, SAT-Implementation Abbreviations: OR, Odds Ratios; SF-12 PCS, Short Form-12 Physical Component Score; SF-12 MCS, Short Form-12 Mental Component Score; PHQ-9, Patient Health Questionnaire -9. *Before Maintenance in Goal practice involves the stages of Pre-contemplation, Contemplation, Preparation. and Action Table 3 Associations of SAT-Life with demographic characteristics, SF-12, and PHQ-9 in the general population For calculating ORs, SF-12 PCS and SF-12 MCS were converted into binary forms with the median value of each of factors as the cutoff value. One OR value, which is from between PHQ-9 and SAT-Life score is relatively low (PHQ-9: ORs = 0.212). PHQ-9 was generated by summing 9 PHQ score, and then subjecting 9 from it. Higher score on PHQ-9 indicate low levels of depression in general. A cutoff of 10 for PHQ-9 was used, because a group with scores equal to or more than 10 is recognized as having severe depression.

Correlations of the SAT-Life with MQOL and SWLS scores
The correlations of the SAT-SF with other factors is shown in  Little is understood about of the role of coping strategies in overcoming life crisis for the general population. The personal sets of the SAT were positively associated with better physical and mental QOL as measured using the SF-12. Our study indicates that these SAT-Life scores were able to differentiate well between the before-maintenance group versus the maintenance group for achieving goals, (Yun et al. 2018b) and between group with high and low scores on depression in the general population. Our ndings may indicate the importance of focusing on coping strategies for prevention of depression. Second, we did not assess test-retest and psychometric properties of this SAT-Life, which may be limited.
Finally, the sensitivity to change such as crisis improvement or progression, or new events, was not assessed. Further cohort studies need to assess its practical utility in the community.
In conclusion, the SAT-Life has appropriate psychometric properties for use with the general population.
Further validation should be carried out in a cohort study across different cultures, including an assessment of sensitivity to change for supporting the practical application and usefulness in community.

Declarations
Informed consent to participate in this public survey is obtained from all participants. Interested and eligible participants receive information about the study of verbal recording.

Consent to publish:
Not Applicable Availability of data and materials (data transparency): The raw data are being kept in the custody of Seoul National University Medical College and are available upon request.
Code availability (software application or custom code): Not applicable.
Authors' contributions: YHY participated in the study design, provided nancial support and study materials, collected and assembled the data, interpreted the analyses, participated in the sequence alignment, drafted the manuscript, and nally approved the paper. JAS participated in the study design and coordination, collected study materials, conducted data analyses, and wrote the manuscript.