Psychometric Testing of The Chinese Version of The Family Crisis Oriented Personal Evaluation Scales In Families of Patients With Dementia


 Background: The Family Crisis Oriented Personal Evaluation Scales (F-COPES) is a widely used instrument to evaluate family coping behaviours. However, no Chinese version of this scale have been developed and validated in China. This study aimed to develop a Chinese version of the F-COPES and evaluate its psychometric properties in the families of patients with dementia who have heavy stress and care burdens.Methods: A cross-sectional study in the specialist memory and geriatric psychiatric clinics of four hospitals in Beijing, China. The English version of the F-COPES was translated into Chinese according to the standard translation guideline. An expert panel was invited to evaluate the content validity index of the Chinese version of this scale. This study included 215 families of patients with dementia. The item homogeneity analysis was conducted by using corrected item-total correlation, corrected item-subscale correlation, and changes of Cronbach’s alpha coefficient of subscales after deleting each item. The factor structure was analysed by using a confirmatory factor analysis. The convergent validity was tested by correlating the F-COPES to the Multidimensional Scale of Perceived Social Support (MSPSS). The internal consistency was assessed by using Cronbach's alpha coefficients of the whole scale and subscales.Results: The content validity index of the Chinese version of the F-COPES was 0.98, with that of each item ranging from 0.83 to 1.00. The result of item homogeneity analysis was satisfactory except for the items in the subscale of passive appraisal. The confirmatory factor analysis identified six subscales; namely, acquiring relatives’ support, acquiring friends’ support, acquiring neighbours’ or others’ support, reframing, seeking spiritual support, and passive appraisal, with acceptable model fit indices (χ2/df = 1.65, CFI = 0.91, GFI = 0.85, TLI = 0.90, PGFI = 0.69, RMSEA = 0.06). The convergent correlation between the F-COPES and the MSPSS was strong (r = 0.50, P < 0.01). The Cronbach's alpha coefficients of the whole scale was 0.86.Conclusion: The Chinese version of the F-COPES showed satisfactory psychometric properties. It may serve as a useful scale for assessing the coping behaviours in families of patients with dementia in China.


Introduction
Dementia is a chronic and progressive syndrome, caused by a variety of brain illnesses affecting memory, thinking, behaviours, and abilities to perform activities of daily living [1]. People with moderate dementia can no longer live independently, and people with severe dementia rely almost entirely on others' caregiving [2]. The number of people living with dementia worldwide is currently estimated at 47 million, expected to increase to 82 million by 2030 [2]. The majority (80%) of people with dementia are receiving care in their homes [3], which leads their families, especially the families of patients with moderate to severe dementia, to have impaired physical and psychological health as a result [4]. The families included the spouses, children, children-in-law, and grandchildren who were living together with the patients or taking care of the patients on a routine basis [5]. The patients' dependence on aspects of daily living causes heavy stress and care burdens to their families [6]. Coping of families refers to speci c efforts that an individual family member or the family functioning as a whole makes to reduce the stress and burden, such as managing the demand on the family system or utilizing coping resources [7]. Coping ability is important in decreasing such stress and promoting family adaptation [8,9]. A tool to identify the coping abilities of families of patients with dementia is necessary to identify vulnerable families with insu cient coping abilities and the coping abilities which they lack, which helps develop interventions to enhance the coping ability of these families.
The Family Crisis Oriented Personal Evaluation Scales (F-COPES) was the most commonly used instrument to measure family coping via self-reporting of family members of medically fragile adults [10].
McCubbin and his colleagues developed and validated the original English version of this scale based on their Resiliency Model, which integrated both internal and external factors in uencing coping abilities of a family (i.e., family resources, social support, and cognition) [7]. In the resilience model, family coping abilities were de ned as the following two levels of efforts: (1) the efforts the family makes to handle di culties and problems via internal resources or cognition inside the family, and (2) the efforts that the family makes to handle problems or demands via externally social support outside family boundaries [7].
The original English version included 30 items and ve subscales, including the subscale of acquiring social support, the subscale of reframing, the subscale of seeking spiritual support, the subscale of mobilizing the family to acquire and accept help, and the subscale of passive appraisal [7]. The original English version has been translated into different languages, resulting in the Persian version, Malay version, and Turkish version, etc. [10][11][12]. Two small studies of Chinese-American and Hong Kong Chinese established Chinese versions of the F-COPES among breast cancer survivors and critically ill patients, respectively [13,14]. However, those Chinese versions cannot be directly used in mainland Chinese populations, due to the distinct social and cultural environments in China [15]. To the best of our knowledge, to date, there are no Chinese versions of this scale developed and validated in mainland China. Thus, in the present study, we developed a Chinese version of the F-COPES using the standard procedure of translation and cultural adaptation, and evaluated its psychometric properties in families of patients with dementia in mainland China.

Setting and sample
The study population was comprised of family members of patients with dementia who visited the specialist memory and geriatric psychiatric clinics of four hospitals in Beijing of China from October 2017 to March 2018. Family members were considered eligible for this study if their relatives with dementia were taken care of at home for at least six months. According to the equations of the minimum sample size ( ), the minimum sample size of our study was 108, when the df = 218, ε = 0.05, the power (1-β) = 0.80, and the (δ is the non-centrality parameter ) [16]. We initially recruited referral, we invited one to two family members of each patient, who were the primary caregivers of each patient to ful l our scales on behalf of the family. In total, 250 family members were invited to participate in our survey. Of those, 25 refused to participate in this study because they had no interest or no time to answer the questions. Thus, a total of 225 family members agreed to participate in this study. For this analysis, we excluded 10 participants who had data missing for more than 10% of the survey. Therefore, the nal sample included 215 participants (Fig. 1). The Ethical Review Committee of School of Nursing, Peking Union Medical College approved the study protocol in April 15 (Approval no. [2015] 03) and the study was conducted in accordance with the principles of the Declaration of Helsinki. All of the participants were informed about the aim and signi cance of this study, their right to quit at any time, and how to ll in the scales. All participants provided written informed consent.

Characteristics of patients and families
Information on the following variates was collected through the questionnaire, including demographic and disease-related characteristics of patients, and demographic characteristics of family members as well as the whole family. The patient information included age, gender, subtypes of dementia (Alzheimer's disease, vascular dementia, and others or unknown), dementia severity based on Clinical Dementia Rating evaluated by the physician (moderate, severe), and time or duration since diagnosis. The information on family members and the whole family included age, educational level (junior middle school and below, high school, college degree, and graduate degree), whether they have religious faith (yes or no), and family income per month per person.

Family Crisis Oriented Personal Evaluation Scales (F-COPES)
The F-COPES was the most commonly used instrument to measure family coping via self-report. It was comprised of 30 item and ve subscales. The ve subscales included a subscale of acquiring social support (the family's behaviours of actively engaging in acquiring support from extended family, friends, and neighbours), subscale of mobilizing the family to acquire and accept help (the family's behaviours of seeking out and using community resources to cope with problems), subscale of seeking spiritual support (the family's behaviours or attitudes of acquiring spiritual support), subscale of reframing (the family's behaviours or attitudes of rede ning stresses/situations to make them more manageable), and subscale of passive appraisal (passive/inactive coping behaviours or attitudes in managing problems).
Respondents were asked to choose the frequency of using different coping methods on a scale of 1 (almost never) to 5 (almost always). Items of Nos. 12, 17, 26, and 28 should be reverse scored when obtaining the total score of the F-COPES by summing the responses of all items. This is due to the fact that the coping behaviours or attitudes described in the items of Nos. 12, 17, 26, and 28 were considered negative. Higher total scores of the F-COPES represent better family coping with stressful situations. The F-COPES has strong internal consistency with Cronbach's alpha coe cient ranging from 0.61 to 0.87 [17,18], and good factorial and concurrent validities [19,20].

Multidimensional Scale of Perceived Social Support (MSPSS)
The MSPSS was selected to evaluate the convergent validity of F-COPES in this study. The MSPSS measured the perceived social support from three informal sources: family, friends, and signi cant other.
Participants were rated on a seven-point Likert response format (1 = "very strongly disagree" to 7 = "very strongly agree"). The total score is summed by the scores of items, with higher scores indicative of greater perceived social support. Zimet et al. [21] tested the MSPSS and reported high internal consistency of 0.88. The test-retest reliability was 0.85 over a 2-to 3-months period after completing the questionnaire [21]. The MSPSS had a Cronbach's alpha coe cient of 0.90 in the current study.

Procedure Translation and adaptation of F-COPES
We conducted a rigorous ''forward-backward'' translation following the guidelines to develop the initial Chinese version of F-COPES [22]. Then, during the adaptation process, we invited six clinical nurse supervisors, nursing researchers, or psychological researchers who were professors or associate professors and familiar with both dementia caregiving and psychometrics to form an expert panel to judge whether each item of the initial Chinese version of F-COPES should be deleted or modi ed and whether we should add other items.
In the adaptation process, we deleted the items of Nos. 9, 29, and 30 from the Chinese version of the F-COPES. Item 9 ("Seeking information and advice from the family doctor") was deleted because the system of family doctors, which is commonly understood internationally, does not exist in China [23].
Item 29 ("Sharing problems with neighbours") was deleted because families of patients with dementia are reluctant to share problems with neighbours when facing the discrimination and prejudice against patients with dementia and their families in China [24,25]. Item 30 ("Having faith in God") was deleted, because only 10.4% of Chinese participants identi ed themselves as religious [26]. Only 6.5% of family members in the current study had religious faith, although they participate in religious practices. We modi ed the items (items of Nos. 14, 23, 27) that described religious practices as coping methods in the subscale of seeking spiritual support. We broadened the Christian terms in these items to comprehensively suit other religions, which was similar to the Turkish version of the F-COPES [12] since the Chinese participants were engaged in some form of religious practice across the various religions [26]. Finally, all experts agreed there was no need to add any new items.

Statistical analysis
After translation and adaptation of the F-COPES, we did a content validity analysis, item homogeneity analysis, factor structure analysis, convergent validity analysis, and internal consistency reliability of the F-COPES. We used AMOS 20.0 software for factor structure analysis and SPSS 17.0 software for other analyses.
Content validity analysis was explored by the item content validity index (I-CVI) and the scale content validity (S-CVI). Six experts were invited to quantify the relevance of items to family coping by using a rating scale (not relevant or somewhat relevant = 0, quite relevant, and very relevant = 1). The I-CVI is the average of all experts rating the results of each item, and S-CVI is the average of I-CVIs. The I-CVI is recommended to be no lower than 0.78 and an S-CVI of 0.80 or higher is acceptable [27,28]. Item homogeneity analysis was tested using a corrected item-subscale correlation, item-total correlation, and Cronbach's alpha coe cient of the subscale after deleting each item. The corresponding item is acceptable if the corrected item-subscale correlation is higher than 0.20, and the value of Cronbach's alpha coe cient of the scale after deleting each item is lower than before the deletion [29].
The factor structure of the F-COPES was analysed by con rmatory factor analysis. The criteria used to determine whether the models of factor structure t the data were 3.00 or lower on the chi-square of model t/degree of freedom (χ 2 /df) [30], 0.90 or greater on the comparative goodness-of-t index (CFI), goodness-of-t index (GFI), and the Tucker-Lewis Index (TLI); 0.50 or greater on parsimony goodness-of-t index (PGFI) [31][32][33][34]; and 0.08 or lower on a root-mean-square error of approximation (RMSEA) [35]. In the con rmatory factor analysis in the current study, the original model established based on the factor structure of the English version of the F-COPES was tested rst. The competing model was then tested if the original model did not meet the above-mentioned criteria [36]. The data tness of the original model and competing models of F-COPES were compared. If the competing model -which meets the above tness criteria and the value of CFI of this model-is at least 0.01 higher than the original model, the competing model is then considered signi cantly better than the original one [37]. Convergent validity of the F-COPES was tested by estimating its correlation with social supports as measured by the MSPSS, since social support has been shown be to be correlated to caregiver coping [38]. The correlation coe cient for convergent validity between 0.10 and 0.29 was considered weak, 0.30 to 0.49 was considered moderate, and 0.50 to 1.0 was considered strong [39]. The internal consistency reliability of the scale and subscales were evaluated by Cronbach's alpha coe cients.
A Cronbach's alpha coe cient between 0.80 and 0.90 was considered perfect, and 0.65 was the lowest acceptable cut point [40].

Results
Demographics Table 1 shows the characteristics of patients and families. Among 215 families, the median age of patients was 82.0 (interquartile range: 76.0-86.0) years old, and 65.1% were women. Alzheimer's disease accounted for 57.2%. The median age of family members were 59.5 (53.3-65.0) years old, and 60.4% had an educational level of a college degree or above. In these families, only 6.5% of the family members had religious faith.

Content validity
The I-CVIs of 24 items in F-COPES were 1.00. Only the I-CVIs of items of 12, 20, 25, and 28 were 0.83 ( 0.78 is acceptable). The S-CVI was equal to 0.98 by calculating the average of the I-CVIs of all items ( 0.80 is acceptable).
Item homogeneity Table 2 shows the results of item homogeneity of each item and the whole scale. The results of item homogeneity tested by the corrected item-subscale correlation were above 0.20 (ranged from 0.28 to 0.84), except for items in the subscale of original passive appraisal (ranged from -0.01 to 0.09). The Cronbach's alpha coe cient of subscales after deleting each item was lower than before, excepts for items in the subscale of original passive appraisal. The results of Cronbach's alpha coe cient had also noticed that the unsatisfactory results of the subscale of passive appraisal may be mistakes in scoring the items in this subscale. According to the negative corrected item-total correlation of items of 12 and 28 in the passive appraisal subscale (-0.26 and -0.50, respectively), we reversed the scoring method of item 12 and item 28 based on the above results and literature review. The corrected item-total correlation of item 12 and item 28 were positive in the modi ed subscale of paasive appraisal. The results of the corrected item-subscale correlation and Cronbach's alpha coe cient of the subscale after deleting each item were improved.
Factor structure Table 3 shows the t statistics for the original factor structure and the competing structure of the Chinese version of the F-COPES in the present study. The values of CFI, GFI, and TLI of the original model did not meet the criteria. We, therefore, established a six-factor competing model based on parts of the original model and the classi cation of social support [41]. In the competing model, we put the following 12 items together: three items in the original subscale of mobilizing the family to acquire and accept help, and nine items in the original subscale of acquiring social support. Then, we divided these 12 items into three new subscales depending on the source of the social support; namely, acquiring relatives' support, acquiring friends' support, and acquiring neighbours' or others' support. The values of CFI and GFI of the competing model met the criteria. Additionally, the value of CFI of the competing model is 0.05 higher than that of the original model, indicating the competing model was signi cantly better than the original one. Figure 2 shows the factor structure of the F-COPES identi ed based on the competing model, including six factor, the correlations between the six factors, the factor-loading from the six factors of the F-COPES to each item, the square of the factor-loading of each item, and the correlation between the errors of items based on standardized estimates. In the competing model, we deleted the correlations between the subscale of seeking spiritual support and the other three subscales of reframing, passive appraisal, and acquiring relatives' support, because the correlations between them were not signi cant (P>0.05). We added the correlations between item 2 and item 16, between item 3 and item 7, between item 4 and item 20, between item 6 and item 10, between item 7 and item 22, and between item 8 and item 10. Table 4 shows the correlation coe cients of each subscale score and the total score of the the Chinese version of the F-COPES with the total score of the MSPSS. The total score of F-COPES had a signi cantly strong correlation with the total score of the MSPSS (r = 0.50, P < 0.01). The six subscales of the F-COPES signi cantly correlated with the total score of the MSPSS, except for the subscale of seeking spiritual support.

Internal consistency reliability
The Cronbach's alpha coe cient of this measure was 0.86. The Cronbach's alpha coe cient of subscales based on the competing factor structure was 0.76 for the subscale of acquiring relatives' support, 0.66 for the subscale of acquiring friends' support, 0.68 for the subscale of acquiring neighbours' or others' support, 0.85 for the subscale of reframing, 0.90 for the subscale of seeking spiritual support, and 0.33 for the subscale of passive appraisal.

Discussion
In the present study in families of patients with dementia in mainland China, we developed a Chinese version of the F-COPES based on the English version and evaluated its psychometric properties. Our Chinese version of this scale showed satisfactory psychometric properties, including content validity, item homogeneity, factor structure, convergent validity, and internal consistency reliability of the whole scale. We also established the six-factor structure of the F-COPES, which is different from other language versions. The F-COPES may serve as a useful scale for assessing the coping behaviours in families of patients with dementia in China. The present study is one of few to develop and validate a Chinese version of the F-COPES in mainland China.

Content validity
The Chinese version of the F-COPES satisfactorily covered relevant domains of family coping, because the relevance of the items (i.e., content validity indexes of the whole scale and items) was perfect. The entire expert panel agreed that the included items in the Chinese version adequately represented the content or behaviours in the domain of family coping. Our ndings are in line with those from several studies of different language versions (i.e., the Persian version and Turkish version ) which reported that the items in the F-COPES were representative internationally [10,12]. This could possibly owe to the integrated and systematic theoretical framework of the F-COPES based on the Resiliency Model developed and validated by McCubbin and his colleagues [6].

Item homogeneity
We found that the items in the subscales for acquiring social support, reframing, seeking spiritual support, and mobilizing the family to acquire and accept help were homogeneous, as indicated by the results of the corrected item-subscale correlation and Cronbach's alpha coe cient of the subscale after deleting each item. These ndings were similar to those from other studies in different countries [10,11].
Of note, the homogeneity of items in the subscales of passive appraisal was unsatisfactory because of the inappropriate original scoring of items 12 and 28 in the Chinese version. In the present study, the homogeneity of items in the passive appraisal subscale was improved after reversing into positive scoring for item 12-"watching TV"-and item 28-"believing if we wait long enough, the problem will go away." Item 12 in our Chinese version of the F-COPES should be positively scored because watching TV has proven to be a very helpful coping behaviour when dealing with high levels of stress [42,43]. We also positively scored item 28, which could be partly supported by the notion that "believing if we wait long enough, the problem will go away" may play a bene cial role in coping mechanisms for Chinese families when facing di culties, because Chinese culture values the virtues of patience, waiting, and forbearance [13].

Factor structure
The subcomponents of family coping that the Chinese version of the F-COPES identi es in families of patients with dementia included acquiring relatives' support, acquiring friends' support, acquiring neighbours' or others' support, reframing, seeking spiritual support, and passive appraisal (Figure 2). This six-factor model of the Chinese version of F-COPES t better the observed data as the results show in Table 3. This model was partly different from other language versions, such as the three-factor Turkish version [12] and the ve-factor African American versions [44]. In the Chinese version, the 12 items in the original subscale of mobilizing the family to acquire and accept help and the subscale of acquiring social support were divided into three new subscales depending on the source of the social support. It supported the suggestion of a previous study, which encourages dividing the coping skills of "acquiring social support" depending on the source of the social support in the Chinese population because of its familism culture [13,45,46].
Besides that, in the Chinese version of F-COPES, the correlations between the subscale of seeking spiritual support and the three subscales-reframing, passive appraisal, and acquiring relatives' supportdisappeared. There were not the same as results of other studies [13,44], perhaps related to different spiritual supporting environments and experiences. Only 6.5% of family members have religious faith in our study, and this is much fewer than other populations [47]. Families' behaviours or attitudes reframing or appraising the stress/situation in our research are mainly rooted in Confucian introspection, forbearance, and perseverance, but not religion [45]. Familism replaced the function of religion in Chinese families and weakened the relationship between the subscale of acquiring relatives' support and the subscale of seeking spiritual support [15]. Finally, the coping behaviours described in item 2 and item 16, item 3 and item 7, item 4 and item 20, item 6 and item 10, item 7 and item 22, and item 8 and item 10 had similar meaning or were correlated with each other as Figure 2 shows.

Convergent validity
The F-COPES had a satisfactory convergent validity. The correlation coe cient for the convergent validity of F-COPES was strong (the correlation coe cient between F-COPES and MSPSS = 0.50, P < 0.01). Through seeing how closely the new scale is related to other measures to which it should be related, this result con rmed that the Chinese version of F-COPES could measure family coping well [29]. The correlation of the subscale of seeking spiritual support with MSPSS was not signi cant because only 6.5% of family members in the current study had religious faith. When they are searching for help, spiritual support is not the common choice [15].

Internal consistency reliability
The Chinese version of F-COPES had perfect internal consistency as the Cronbach's alpha coe cient of this measure was 0.86. The internal consistency reliability of the subscales were good as well, except for the passive appraisal subscale. This nding was similar to that in another study [13]. There are two possible explanations for this result. First, this result could be due to the population it measured. The passive appraisal is always the least used coping method among the families of patients with dementia [48]. In the current study, more than half of the family members only used one or two of these four coping methods, thereby in uencing the internal consistency. Secondly, it might be associated with the fact that there were only four items in this subscale [49]. Taken together, our ndings suggested we should add more items in this subscale focusing on the family members of patients with dementia to improve its internal consistency reliability by increased applicability and appropriate item redundancy.

Strength and limitations
The major strength of this study was that we developed the Chinese version of F-COPES and evaluated the psychometric of it in families of patients with dementia, including content validity, item homogeneity, factor structure, convergent validity, and internal consistency reliability of the F-COPES. Our research also has limitations. First, some items should be added, especially in the subscale of passive appraisal. Second, we urge caution in generalizing our ndings to other populations since the study population was restricted to families of patients with dementia; future studies among other populations are warranted to con rm our ndings.

Conclusion
This study demonstrated that the Chinese version of the F-COPES showed satisfactory psychometric properties. Our ndings suggest that it may serve as a useful scale for assessing the coping behaviours in families of patients with dementia from the perspective of the family systems in China.

Consent for publication
Not applicable.

Competing interests
The authors declared no potential con icts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The authors received nancial support from Natural Science Foundation of Jiangsu Province (BK20201016) and Higher Education Philosophy and Social Science Foundation of Jiangsu Province (2019SJA0944). The funders had not directly role in the design, data collection, analysis, interpretation or writing of the manuscript.
Authors' contributions QW was involved in the conception and design, acquisition of data, analysis, and interpretation of data, drafting and revising manuscript; SC and WL participated drafting and revising of the manuscript; YS contributed to the design, planning, coordination, and revision of manuscript. All authors have read and approved the manuscript.  Note. a. If Cronbach's alpha coe cient of the subscale after deleting any item is higher than before, it means that the item has low homogeneity to other items.
b. Since corrected item-total correlation of item 12 and item 28 in the original subscale of passive appraisal were negative (-0.26 and -0.50, respectively), the scoring method of item 12 and item 28 were reversed, and the corrected item-total correlation, corrected item-subscale correlation and Cronbach's alpha coe cient of the subscale after deleting each item of the modi ed subscale of passive appraisal were increased. Note. χ 2 /df = chi-square of model t/df; CFI = comparative goodness-of-t index; GFI = goodness-of-t index; TLI = Tucker-Lewis Index; PGFI = parsimony goodness-of-t index; RMSEA = root mean square error of approximation.
The following criteria were used to determine whether the models t the data, including 3.00 or lower on the χ 2 /df; 0.90 or greater on the CFI, GFI, and TLI; 0.50 or greater on PGFI; and an RMSEA of 0.08 or lower.
The model that meets the above-mentioned tness criteria and the value of CFI of the model is higher than the another model (△CFI 0.01), indicates it is signi cantly better than the another model.   Figure 1 Assembly of the study sample The factor structure of Chinese version of F-COPES