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International Journal of Nursing Practice 2014; ••: ••–••

RESEARCH PAPER

Psychometric testing of the Chinese Mandarin version of the MacNew Heart Disease Health-related Quality of Life questionnaire for patients with myocardial infarction in mainland China Wenru Wang PhD RN Assistant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Ying Lau PhD RN Assistant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Sabrina Palham MSN RN Lecturer, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Aloysius Chow BPsych (Hons) Research Assistant, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Hong-gu He PhD RN Assistant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Accepted for publication May 2013 Wang W, Lau Y, Palham S, Chow A, He H. International Journal of Nursing Practice 2014; ••: ••–•• Psychometric testing of the Chinese Mandarin version of the MacNew Heart Disease Health-related Quality of Life questionnaire for patients with myocardial infarction in mainland China Tools to measure the quality of life of Chinese myocardial infarction (MI) patients in mainland China are small in numbers. For this study, 210 Chinese patients with MI were recruited to examine the psychometric properties of the Chinese Mandarin version of the MacNew Heart Disease questionnaire. Thirty-five participants managed to complete the retest after 2 weeks. The MacNew Heart Disease questionnaire had acceptable internal consistency, test–retest reliability and concurrent validity. The principal components analysis identified three factors which accounted for 56.6% of the variance. The MacNew Heart Disease questionnaire demonstrated good reliability and validity to be used as a health status measurement tool, and is ready for clinical use in the assessment of the quality of life of Chinese MI patients in mainland China. Key words: Chinese Mandarin, cross-cultural validation, health-related quality of life, myocardial infarction.

Correspondence: Wang Wenru, Alice Centre for Nursing Studies, Yong Loo Lin School of Medicine, Level 2, Clinical Research Centre, Block MD 11,10 Medical Drive, Singapore. Email: [email protected] doi:10.1111/ijn.12238

© 2014 Wiley Publishing Asia Pty Ltd

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INTRODUCTION Coronary heart disease (CHD) is becoming a serious health problem in mainland China whose people are experiencing a rapidly expanding economy and modernization. In the last decade, myocardial infarction (MI) has been identified as a major cause of increased mortality and morbidity rates for patients with CHD.1 Patients with MI often experience physical, emotional and mental strain, which leads to a lower health-related quality of life (HRQoL).2 Therefore, changes in the HRQoL of an individual have been more frequently used as a health indicator when making clinical decisions and reviewing the efficacy of treatment.3 The method used to measure HRQoL should reflect the concepts of the quality of life and hence is of critical importance to select measurement instruments that reflect the patient’s satisfaction with the multiple dimensions of life which incorporate the physical, psychological and social domains.4 Over the past decades, the evaluation of HRQoL has been facilitated by the development of instruments that provide information from the perspective of the individual person. Measurement tools for HRQoL have been developed to be either generic or disease specific. Generic versions of the tools that measure HRQoL consider the types and severity of disease and treatment across different populations. In contrast, disease-specific versions of the tools examine HRQoL relevant to populations with specific diseases or symptoms.4 Furthermore, these specific measurement instruments are sensitive to any vicissitudes to the health condition of an individual and are unlikely to be affected by the ceiling or floor effect.5 The Quality of Life after Myocardial Infarction Questionnaire was a tool created in English and used for survivors of an acute MI episode.6 A modification of this questionnaire was developed and was entitled the MacNew Questionnaire.7 This questionnaire was developed to assess how much CHD, and the ensuing treatment, affected a patient’s physical and emotional status and also their daily social functioning.8 Over 27 test items, the MacNew Questionnaire measures the individual’s emotional and social functioning level, physical limitations while providing a global HRQoL score.7 Several studies have shown that the MacNew Questionnaire retained satisfactory standards of psychometric properties like validity, reliability, sensitivity and acceptability despite being translated into different languages.7,9–12 In addition, the MacNew Questionnaire is robust and widely © 2014 Wiley Publishing Asia Pty Ltd

used for assessing HRQoL of patients with MI and evaluating the effectiveness of medical treatments,13,14 secondary prevention and cardiac rehabilitation programmes,15,16 as well as various behavioural interventions.17,18 A traditional Chinese version of the MacNew Questionnaire was rigorously translated and validated for Cantonese-speaking patients with CHD in Hong Kong, and was demonstrated as a valid and reliable instrument for measuring their health status.12 Although the language used in Taiwan, Hong Kong and mainland China is Chinese, there are differences in the way people in each of these regions write certain characters. Specifically, the traditional writing system is subscribed to by people in Hong Kong and Taiwan, whereas a simplified writing system is utilized by people in mainland China. The MacNew Questionnaire has been validated in Hong Kong, where the cultural, economic, linguistic and political environment is significantly different from mainland China. Therefore, this study aimed to test the reliability and validity of the simplified Chinese version of the MacNew questionnaire (Chinese Mandarin version) in mainland China.

METHODS Study sample and setting A cross-sectional design involving a sample group was used to examine the reliability and validity of the Chinese Mandarin version instrument in this study. The recruitment of a convenience sample of 210 MI patients was conducted at two hospitals which were affiliated to a university in Xi’an, China. The criteria used to identify the study participants were that they had a diagnosis of MI, had no known major psychiatric diagnosis, had no severe mobility problems and could comprehend simplified Chinese characters.

Data collection Ethical approval was obtained from two study hospitals in Xi’an city of mainland China. Eligible patients based in the cardiac inpatient and outpatient wards of the hospitals were invited to participate in the study by a research assistant over a 6 month period. Eligible patients who agreed to take part were given an information sheet which outlined the aim and procedure of the study, after written consent was obtained from them. Once enrolled into the study, participants had to spend approximately 20 min answering three self-administered questionnaires. Together with their medical charts, the participants were

Psychometrics of Chinese version MacNew

interviewed to collate demographic and medical data. For evaluating the test–retest reliability, a repeated administration of the instruments took place among 20% from the principal group of subjects (n = 42) 2 weeks later.

Instruments The Chinese version of the MacNew Health-related Quality of Life Questionnaire (CM:MacNew) Over 27 test items, the MacNew Questionnaire measures the individual’s emotional and social functioning level, physical limitations while providing a total score. These measurements are scaled against a Likert scale ranging from a score of 1 to 7 which translates to poor HRQoL to high HRQoL, respectively. To detect a significant clinical change, the minimal importance difference (MID) is used to calculate the minimum score needed to show this change; the MID for the MacNew Questionnaire was reported to be 0.5, which implies that a minimum change of scores by 0.5 points translates to a significant clinical change in the participant.8,12 The MacNew Questionnaire has been translated and validated into a Chinese version for Chinese patients with CHD in Hong Kong, whereas the Chinese Cantonese version questionnaire has a satisfactory internal consistency with Cronbach’s α coefficients of 0.93 for the Global scale and 0.88–0.91 for three domains.12 It was reported that the test–retest reliability when using intraclass correlations was 0.95 for the Global scale and from 0.88 to 0.93 for the three domains.12 For the current study, the Chinese Cantonese version of the MacNew Questionnaire that is presented in traditional Chinese characters was transformed into a version with simplified Chinese characters. Minor modification was made so that the expression of a few items was more easily understood by Mandarin-speaking Chinese.

The Chinese Mandarin version of the Short Form-36 health survey (CM:SF-36) An increasingly popular scale used to measure the HRQoL of cardiac patients is the SF-36. The SF-36 consists of eight domains including physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional and mental health.19 An item included in the questionnaire was to compare the health condition of the participant currently from what the condition was a year ago. Each subscale score ranged between 0 and 100, and the physical and mental component summary subscale scores could be obtained, with a higher score indicating better HRQoL.19 It has been reported that reliability

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levels in more than 25 group comparative studies have exceeded 0.70 except with rare exceptions, and most were above 0.80.19 The Chinese Mandarin version of the instrument used in the current study was reported to have high levels of reliability and validity when used with Chinese CHD patients.20 Specifically, the amount of internal consistency for every subscale was satisfactory (Cronbach’s α 0.71–0.93), with an exception for the General Health subscale (Cronbach’s α 0.64). Using the intraclass correlation coefficient (ICC), the test–retest reliability was reported to be satisfactory, with the ICC greater than 0.70 for every subscale.20

The Chinese Mandarin version of Hospital Anxiety and Depression Scale (CM:HADS) The Hospital Anxiety and Depression Scale (HADS), which contains seven items measuring anxiety and the remaining seven items measuring depression,21 has been used widely on different patient groups including cardiac clients.22,23 Responses for each item in the HADS are measured with a four-point scale, with a higher score reflecting a higher level of anxiety and depression. The CM:HADS was reported to have acceptable reliability and validity when used for Chinese CHD patients.24 It was reported that Cronbach’s α for the scale and its individual anxiety and depression subscales were 0.85, 0.79 and 0.79, respectively.24

Data analysis The Chinese Mandarin versions of the MacNew, SF-36 and HADS were analysed using descriptive and inferential statistics. The internal consistency was analysed by estimating the amount of correlation between each item with the total using Spearman correlation coefficients and by calculating Cronbach’s alpha. To measure the effect of an item on the subscale when it is omitted, the item to total correlation ratio is a reference used and should exceed 0.4.25 Test–retest reliability was assessed using ICC, with r > 0.70 as an acceptable cut-off for comparing groups.26 Concurrent validity was determined by comparing the correlations of the CM:SF-36 physical and mental domains, the CM:HADS anxiety and depression subscales, and the similar CM:MacNew scale constructs. A two-tailed Pearson correlation was used to set up concurrent validity and a higher correlation coefficient between related dimensions was ascertained to be satisfactory (r ≥ 0.6).27 The Pearson correlation was chosen as the variables conform to the parametric assumptions of © 2014 Wiley Publishing Asia Pty Ltd

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normal distribution and homogenous of variance.27 To check the discriminant validity of the CM:MacNew questionnaire, the ‘known-groups’ test was used.28 The expected relationships were performed with age, gender, co-morbidity with heart failure, the cut-off scores for clinical anxiety and depressive symptoms for the HADS (anxiety and depression scores ≥ 11), and health transition items in the SF-36 (scores 4 and 5 = deteriorated, scores 1, 2 and 3 = not deteriorated). The most common approach to validate constructs is to utilise Factor Analysis, which is accepted as a powerful statistical tool that explicates the underlying significance of concepts.27 The construct validity of the CM:MacNew used in the current study was measured using the principal component analysis and varimax rotation.

RESULTS Characteristics of subjects A total of 315 patients were screened for their eligibility to participate in the current study over the 6 months span of this study. Of these, 257 (62.7%) who met the inclusion criteria were initially enrolled into the study, and 210 (91.9% of the study subjects) completed the questionnaires. Thirty-five participants completed the secondtime questionnaire measurements. The demographic features of the participants who completed the questionnaires the first time are summarized in Table 1. There were 171 (81.4%) men and 39 (18.6%) women. The participants had an age range of 34–83 years with a mean of 61.2 years (SD = 14.3). One hundred and seventyfour (82.6%) patients were married and more than half (n = 138, 65.7%) reported to have attained over 6 years of education. The clinical information collected showed that a high percentage of subjects had hypertension (61.0%) and hypercholesterolaemia (69.5%), and 31 (14.8%) patients had the comorbidity of heart failure (Table 1).

Table 1 Socio-demographic and clinical characteristics of the sample (n = 210) Variables Age (years) 13) Smoker Yes No Coronary family history Yes No Diabetes Yes No Hypercholesterolaemia Yes No Hypertension Yes No Heart failure Yes No

Frequency

Percent

118 92

56.2 43.8

171 39

81.4 18.6

174 36

82.6 17.4

72 88 50

34.3 41.9 23.8

61 149

29.0 71.0

36 174

17.1 82.9

58 152

27.6 72.4

145 65

69.5 30.5

128 82

61.0 39.0

31 179

14.8 85.2

Unmarried includes single, divorced or widowed.

Concurrent validity Internal consistency and reliability The correlation coefficients between items and the rest of their respective scales ranged between 0.48 and 0.88 for the three subscales of the CM:MacNew (Table 2), providing evidence of internal consistency. Cronbach’s alpha of the Global and subscales were found to be acceptable, with 0.90 for the Global scale and 0.80 to 0.89 for the subscales. Because the ICC scores were found to be more than 0.70, the test–retest reliability was of a satisfactory level (Table 2). © 2014 Wiley Publishing Asia Pty Ltd

Considering the specific analyses of similar domains, significant correlations were found between the CM: MacNew and CM:SF-36 (Table 3); specifically there were high correlations between the CM:MacNew physical subscale and the CM:SF-36 physical component subscale (PCS) (r = 0.736, P < 0.001) and also between the CM:MacNew emotional subscale and the CM:SF-36 mental component subscale (MCS) (r = 0.629, P < 0.001), respectively. The concurrent validity for the CM:MacNew was also established based on the high

Psychometrics of Chinese version MacNew

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Table 2 Internal consistency (item to total correlations and Cronbach’s α) and test–retest reliability of the Chinese Mandarin version of the MacNew Items

Item to total correlation (n = 210)

Cronbach’s α (n = 210)

Intraclass coefficient (n = 35)

Physical limitations (Items 9, 14, 16,19 and 20) Emotional function (Items 1, 2, 3, 4, 5, 6, 7, 8, 10 15 and 18) Social function (Items 11, 12, 13, 17, 21,22, 23, 24, 25 and 26) Global score

0.48–0.82 0.51–0.80 0.62–0.88 0.31–0.87

0.89 0.86 0.80 0.90

0.88 0.78 0.83 0.85

Table 3 Pearson correlations of the association between the Chinese Mandarin versions of the MacNew and the SF-36 domains and the HADS anxiety and depression subscales (n = 210) CM:MacNew HRQoL questionnaire Global scale CM:SF-36 SF-36 PCS SF-36 MCS CM:HADS Anxiety subscale Depression subscale

Physical subscale

Emotional subscale

Social subscale

0.610** 0.542**

0.736** 0.406*

0.478* 0.629**

0.545** 0.525**

−0.598** −0.687**

−0.469** −0.560**

−0.691** −0.740**

−0.451* −0.528**

* Significant at 0.01, ** Significant at 0.001. HADS, Hospital Anxiety and Depression Scale; HRQoL, health-related quality of life; MCS, mental component subscalel; PCS, physical component subscale; SF-36, Short Form-36.

correlations between the CM:MacNew emotional and the CM-HADS anxiety scale (r = −0.691, P < 0.001) and depression scale (r = −0.740, P < 0.001).

perceived health deterioration was compared with participants who reported none of these conditions, the MID of 0.5 was exceeded (Table 4).

Discriminant validity

Factor structure

Female patients scored significantly lower in the CM:MacNew Global scale and physical subscale. The mean scores of the CM:MacNew Global scale and physical subscale were statistically lower among older patients. Patients without heart failure reported notably higher scores on every CM:MacNew scale than those with comorbidity of heart failure. Patients who did not report any decline in their health condition had notably higher scores on each CM:MacNew scale than patients who perceived deterioration. Significantly lower scores in each CM:MacNew domain were observed in patients with anxiety and depression. When each CM:MacNew domain score differential of participants who had heart failure, symptoms of anxiety, symptoms of depression and had

The data were found to meet the assumptions of factor analysis. The Kaiser–Meyer–Olkin analysis generated a ratio of 0.77 which exceeded the recommended score of 0.60. The analysis also found that Bartlett’s test of sphericity was χ2 (595) = 4172.145 (P ≤ 0.001).29 The principal component analysis showed three factors which had eigenvalues of more than one and were linked to 56.6% of the variance. The varimax rotation factor analysis established the components (Table 5). The cut-off point used in the current study was a loading criterion of 0.40,30 and the items related to the three-factor solution were generated in Table 5. It was found that item 6 loaded on factors 1 and 2, whereas items 12, 15 and 23 were observed to load on factors 1 and 3. © 2014 Wiley Publishing Asia Pty Ltd

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Table 4 Discriminant validity of the CM:MacNew questionnaire by age, gender, anxiety, depression and perceived health status CM:MacNew questionnaire

Gender Male (n = 171) Female (n = 39) P value Age < 65 years (n = 118) ≥ 65 years (n = 92) P value Co-morbidity with HF Yes (n = 31) No (n = 179) P value Anxiety (C-HADS) Anxious (HADS 11+) (n = 41) Not anxious (n = 169) P value Depression (C-HADS) Depressed (HADS 11+) (n = 14) Not depressed (n = 196) P value CSF-36 health transition Deteriorated (n = 178) Not deteriorated (n = 32) P value

Global scale

Physical subscale

Emotional subscale

Social subscale

4.82 ± 0.71 4.57 ± 0.86 0.024

4.77 ± 0.86 4.29 ± 0.86 0.001

4.87 ± 0.76 4.79 ± 0.66 0.643

4.78 ± 0.74 4.74 ± 0.83 0.457

4.92 ± 0.75 4.42 ± 0.85 0.031

4.82 ± 0.87 4.33 ± 0.79 0.039

4.79 ± 0.81 4.76 ± 0.78 0.117

4.82 ± 0.78 4.78 ± 0.68 0.213

4.42 ± 0.75 4.92 ± 0.69 0.008

4.37 ± 0.85 4.93 ± 0.65 0.012

4.21 ± 0.88 4.78 ± 0.65 0.016

4.41 ± 0.75 4.87 ± 0.78 0.032

4.10 ± 0.64 4.85 ± 0.74 0.000

4.32 ± 0.73 4.89 ± 0.66 0.001

3.81 ± 0.75 4.89 ± 0.75 0.000

4.08 ± 0.74 4.91 ± 0.66 0.000

3.89 ± 0.62 4.82 ± 0.76 0.000

4.12 ± 0.61 4.88 ± 0.78 0.001

3.53 ± 0.54 4.78 ± 0.70 0.000

3.76 ± 0.81 4.84 ± 0.71 0.000

4.68 ± 0.67 5.21 ± 0.58 0.000

4.46 ± 0.61 5.30 ± 0.60 0.000

4.68 ± 0.71 5.19 ± 0.66 0.005

4.71 ± 0.74 5.34 ± 0.61 0.001

HADS, Hospital Anxiety and Depression Scale; HF, heart failure.

DISCUSSION Although a recent study conducted in Hong Kong has shown the Chinese Cantonese version of the MacNew questionnaire to be reliable and valid for Chinese patients with MI,12 the direct application of the instrument validated within a Hong Kong population to the patients in mainland China was arguably highly problematic due to the variances in the social and cultural contexts of Hong Kong and mainland China. As a result it was necessary to examine the psychometric properties of the Chinese Mandarin version of the MacNew Questionnaire which was created in simplified Chinese characters, for MI patients in mainland China. The results indicate that the CM: MacNew meets the psychometric standards, which are comparable with a similar study that was conducted in Hong Kong,12 and adds on to the psychometric data of © 2014 Wiley Publishing Asia Pty Ltd

the MacNew Questionnaire for MI patients who speak different languages.7,9–12,31 Results of this study show that the CM:MacNew demonstrated satisfactory internal consistency, surpassing the standard for instruments that are commonly used and reputable.27 The internal consistency of the CM:MacNew was demonstrated by the high correlation found between the items with their respective scale. The high ICC found added support to the observation of the stable scores recorded over a 2 week period. Hence the CM:MacNew was found to have homogeneity and the scores were not expected to vary significantly should it be administered repeatedly within a 2 week period. Three significantly high correlations were found, which are comparable with previous studies conducted in Hong Kong,12 the UK,7 Germany10 and Brazil.31 These

Psychometrics of Chinese version MacNew

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Table 5 Factor weights and variance explained from factor analysis

1. Frustrated 2. Worthless 3. Confident 4. Down in the dumps 5. Relaxed 6. Worn out 7. Happy with personal life 8. Restless 9. Shortness of breath 10. Tearful 11. More dependent 12. Social activities 13. Others/less confidence in you 14. Chest pain 15. Lack self-confidence 16. Aching legs 17. Sports/exercise limited 18. Frightened 19. Dizzy or lightheaded 20. Restricted or limited 21. Unsure about exercise 22. Overprotective family 23. Burden on others 24. Excluded 25. Unable to socialize 26. Physical activity 27. Sexual activity† Variance explained

Emotional (Factor 1)

Original MacNew

Physical (Factor 2)

Original MacNew

Social (Factor 3)

Original MacNew

0.66 0.70 0.65 0.70 0.64 0.57 0.78 0.67 0.14 0.65 0.21 0.64 0.31 0.18 0.78 0.20 0.28 0.47 0.28 0.27 0.15 0.34 0.58 0.11 0.26 0.16

0.79 0.74 0.61 0.86 0.79 0.59 0.73 0.81 0.24 0.72 0.39 0.40 0.45 0.17 0.67 0.39 0.23 0.63 0.39 0.21 0.34 0.18 0.44 0.19 0.23 0.17

0.17 0.05 0.03 0.13 0.13 0.41 0.19 0.04 0.87 0.13 0.05 0.33 0.12 0.58 0.13 0.67 0.72 0.09 0.75 0.86 0.59 0.10 0.34 0.69 0.39 0.78

0.25 0.16 0.26 0.22 0.26 0.52 0.21 0.29 0.73 0.17 0.20 0.46 0.08 0.72 0.19 0.44 0.60 0.25 0.61 0.64 0.47 0.00 0.20 0.43 0.46 0.60

0.04 0.35 0.26 −0.03 0.05 0.14 0.09 0.02 0.11 −0.03 0.33 0.67 0.45 0.04 0.49 0.02 0.12 0.08 0.11 0.27 0.23 0.44 0.46 0.33 0.77 0.27

0.15 0.42 0.37 0.23 0.21 0.17 0.28 0.21 0.32 0.20 0.62 0.52 0.66 0.17 0.47 0.05 0.61 0.36 0.07 0.62 0.48 0.69 0.66 0.74 0.68 0.65

27.3%

26.6%

18.3%

23.0%

11.0%

9.7%

Item 27 was not included in the factor analysis based on original report. 7 Factor loading (loading ≥ 0.40), for each MacNew item in the Chinese Mandarin version (underlined and boldfaced) together with the factor loadings (loading ≥ 0.40) from the original factor analysis (boldfaced).7 †

correlations are between the CM:MacNew physical subscale and the CM:SF-36 PCS, between the CM:MacNew emotional subscale and the CM:SF-36 MCS, and between the CM:HADS anxiety and depression subscales with the CM:MacNew emotional subscale. These high correlations are expected because these instruments have good internal reliability and measure the same concepts. However, it was observed that the CM:SF:36 PCS had significant correlations with the CM:MacNew emotional and social subscales. This is not unsurprising because physical health status will affect the emotional and social functioning of any individual.32

The satisfactory discriminant validity of the CM: MacNew was also confirmed in this study. Compared with male or younger patients, female and older patients were found to have significantly lower HRQoL based on the scores of both the Global and physical scales of the CM:MacNew; whereas participants with heart failure were found to have significantly lower scores on the Global, physical, emotional and social subscales. These observations seemed in line with what was reported in previous studies,10,12,31,33 that the CM:MacNew discriminated well between the perceptions of health deterioration and non-deterioration, based on the score of the © 2014 Wiley Publishing Asia Pty Ltd

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health transition item in the SF-36. Additionally, the presence of depression or anxiety was significantly associated with lower level of HRQoL measured by the CM: MacNew in this study, substantiating the observation made by Yu and colleagues in their study.12 In the CM:MacNew, the three-factor solution and the loading on the individual items were most consistent with the initial factor structure (Table 5). However, adopting a factor weight of ≥ 0.4, several items were loaded onto more than one subscale. The same observation has been reported both in the original6,7 and a number of other validation studies of the MacNew.10,12,31 The validity of this factor structure has been argued12,34 because a test item ought to be loaded onto the subscale with the largest factor weight if the principal component analysis is adopted.35 Hence there have been suggestions that a re-evaluation of the factor structure used in the MacNew Questionnaire should be conducted.12,34 The observations made from the current study is comparable with previous studies of the psychometric properties like the reliability and validity of the MacNew Questionnaire for MI patients based in Hong Kong12 and other countries.7,9–11,31 Although the results of the current study support the use of the MacNew Questionnaire as a main HRQoL measurement tool for Chinese-speaking patients with MI,12 the generalizability of the scale is prevented by geographic issues. China is populated by people from 51 different tribes which have slight variation in linguistic practices, though a common Pu Tong Hua has been gaining popularity in recent years. The current findings show that the CM:MacNew has acceptable validity and reliability as clinical tool to measure the health condition of Chinese MI patients in mainland China. It is recommended that further work be done regarding the psychometric properties and the sensitivity of the CM:MacNew, so that it can be used in clinical trials by more people from different groups in China.

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CONFLICT OF INTEREST None.

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Psychometric testing of the Chinese Mandarin version of the MacNew Heart Disease Health-related Quality of Life questionnaire for patients with myocardial infarction in mainland China.

Tools to measure the quality of life of Chinese myocardial infarction (MI) patients in mainland China are small in numbers. For this study, 210 Chines...
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