Doris Y. P. Leung

Three versions of Perceived Stress Scale: validation in a sample of Chinese cardiac patients who smoke

BackgroundSmoking causes heart disease, the major cause of death in China and Hong Kong. Stress is one major trigger of smoking and relapse, and understanding stress among smoking cardiac patients can therefore help in designing effective interventions to motivate them to quit. The objective of this study was to examine the psychometric properties of the Perceived Stress Scale (PSS), and to compare the appropriateness of the three versions of the scale (PSS-14, PSS-10, and PSS-4) among Chinese cardiac patients who were also smokers.MethodsFrom March 2002 to December 2004, 1860 cardiac patients who smoked were recruited at the cardiac outpatient clinics of ten acute hospitals in Hong Kong, and 1800 questionnaires were analysed. Participants completed a questionnaire including the PSS, nicotine dependence and certain demographic variables. The psychometric properties of the PSS were investigated: construct validity using confirmatory factor analysis, reliability using Cronbachs alpha and concurrent validity by examining the relationship with smoking- and health-related variables.ResultsFor all the three versions of the PSS, confirmatory factor analyses corroborated the 2-factor structure of the scale, with the positive and negative factors correlating significantly and negatively to a moderate extent (r < -0.5), and high Cronbachs alpha values for the two subscales (alpha > 0.5). All the correlations of the two subscales and the smoking- and health-related variables were statistically significant and in the expected directions although of small magnitudes, except daily cigarette consumption.ConclusionsThe findings confirmed the satisfactory psychometric properties of all three Chinese versions of PSS. We recommend the use of PSS-10 for research which focuses on the two components of perceived stress, as it shows a higher reliability; and the use of PSS-4 if such partition is not essential and space for multiple measures is limited.

Prevention of Acute Myocardial Infarction and Stroke among Elderly Persons by Dual Pneumococcal and Influenza Vaccination: A Prospective Cohort Study

BACKGROUND Despite World Health Organization recommendations, the rate of 23-valent pneumococcal (PPV) and influenza (TIV) vaccination among elderly persons in Hong Kong, China, is exceptionally low because of doubts about effectiveness of vaccination. The efficacy of dual vaccination remains unknown. METHODS From 3 December 2007 to 30 June 2008, we conducted a prospective cohort study by recruiting outpatients aged ≥65 years with chronic illness to participate in a PPV and TIV vaccination program. All were observed until 31 March 2009. The outcome of subjects, including the rates of death, hospitalization, pneumonia, ischemic stroke, acute myocardial infarction, and coronary and intensive care admissions, were determined. RESULTS Of the 36,636 subjects recruited, 7292 received both PPV and TIV, 2076 received TIV vaccine alone, 1875 received PPV alone, and 25,393 were unvaccinated, with a duration of follow-up of 45,834 person-years. Baseline characteristics were well matched between the groups, except that there were fewer male patients in the PPV and TIV group and fewer cases of comorbid chronic obstructive pulmonary disease among unvaccinated persons. At week 64 from commencement of the study, dual-vaccinees experienced fewer deaths (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.55-0.77]; P<.001) and fewer cases of pneumonia (HR, 0.57; 95% CI, 0.51-0.64; P<.001), ischemic stroke (HR, 0.67; 95% CI, 0.54-0.83; P<.001), and acute myocardial infarction (HR, 0.52; 95% CI, 0.38-0.71; P<.001), compared with unvaccinated subjects. Dual vaccination resulted in fewer coronary (HR, 0.59; 95% CI, 0.44-0.79; P<.001) and intensive care admissions (HR, 0.45; 95% CI, 0.22-0.94; P=.03), compared with among unvaccinated subjects. CONCLUSIONS Dual vaccination with PPV and TIV is effective in protecting elderly persons with chronic illness from developing complications from respiratory, cardiovascular, and cerebrovascular diseases, thereby reducing hospitalization, coronary or intensive care admissions, and death.

Examining the Cultural Specificity of Approaches to Learning in Universities in Hong Kong and Sydney

Western research has characterized approaches to learning for specific learning tasks as discrete deep and surface approaches, distinguished by whether the intention is to understand or memorize. A more appropriate classification scheme for Hong Kong research is a continuum between deep and surface poles. In this article, the authors examine whether this characterization applies also to the West. University students in Australia (n = 1,146) and Hong Kong (n = 1,266) complete the revised Study Process Questionnaire. There are no effects by either discipline or study level in either country. Multiple-group analyses using structural equation modeling show configural invariance across the two samples, suggesting that the continuum characterization of approaches to learning is likely to be applicable for Western counterparts. Hong Kong students had higher mean scores for both deep and surface approaches, showing their greater use of intermediate approaches.

Psychometric evaluation of the Hospital Anxiety and Depression Scale in a large community sample of adolescents in Hong Kong

PurposeThe Hospital Anxiety and Depression Scale (HADS) is widely used in adult populations; however, its usefulness with adolescents has been explored less. This study sought to evaluate the reliability, validity, and factor structure of the Chinese version of HADS in a community sample of adolescents residing in Hong Kong.MethodsA prospective cohort of 5,857 students recruited from 17 secondary schools completed the HADS. Internal consistency and concurrent validity were examined. Confirmatory factor analysis was applied to test the relative fits of six factor structures of the HADS. The best fitting model was further cross-validated by male, female, split-half samples, and age subgroups.ResultsThe HADS possessed adequate internal consistency, especially for the anxiety subscale. Significant concurrent intercorrelations with self-reported suicidal thoughts and the Youth Self Report Anxious/Depressed subscale were discovered and found to be stronger for females. The cross-validation supported a two-factor model, where anxiety item 7, “I can sit at ease and feel relaxed”, was placed in the depression subscale.ConclusionsThe HADS showed satisfactory psychometric properties as a screening instrument in assessing anxious and depressive states as two correlated but distinct factors in adolescents. Study implications and recommendations for future research were discussed.

A workshop activity to demonstrate that approaches to learning are influenced by the teaching and learning environment

It is important to demonstrate to those taking courses for new teachers that approaches to learning have a relational nature — that they are influenced by the teaching and learning context. This article describes a workshop activity, based on the Revised Study Process Questionnaire. Workshop participants recorded their approaches to learning in two contexts: how they currently studied as postgraduate students, and how they studied in their most disliked undergraduate course. Analysis of the results from this activity indicates that approaches to learning are markedly influenced by the teaching and learning environment. This provides a graphic demonstration to workshop participants of the importance of their teaching, as it will have a strong influence on the quality of learning of their students. The data from the activity give quantitative evidence of the relational nature of approaches to learning. Further, there appears to be a discipline effect operating with the nature of the typical teaching and learning environment in the arts, humanities and social sciences being more conducive to students cultivating a deep approach to learning.

A randomized controlled trial of a smoking reduction plus nicotine replacement therapy intervention for smokers not willing to quit smoking

AIMS To examine the effectiveness of smoking reduction counselling plus free nicotine replacement therapy (NRT) for smokers not willing to quit. DESIGN, SETTING AND PARTICIPANTS A total of 1154 Chinese adult smokers not willing to quit but who were interested in reducing smoking were allocated randomly to three arms. Intervention group A1 (n=479) received face-to-face counselling on smoking reduction and adherence to NRT at baseline, 1 week and 4 weeks with 4 weeks of free NRT. Group A2 (n=449) received the same intervention, but without the adherence intervention. Control group B (n=226) received simple cessation advice at baseline. MEASUREMENTS Self-reported 7-day point prevalence of tobacco abstinence and reduction of cigarette consumption (≥50%) at 6 months and continuous use of NRT for 4 weeks at 3 months. FINDINGS Using intention-to-treat analysis, compared to control group B, the intervention groups (A1+A2) had achieved higher 6-month tobacco abstinence (17.0% versus 10.2%, P=0.01) and reduction rates (50.9% versus 25.7%, P<0.001). There was no significant difference in the 4-week NRT adherence rate at 3 months, but group A1 achieved a higher abstinence rate than group A2 at 6 months (20.9% versus 12.9%; P=0.001). CONCLUSIONS In smokers with no immediate plans to quit, smoking reduction programmes with behavioural support and nicotine replacement therapy are more effective than brief advice to quit. Current guidelines recommend advice to quit on medical grounds as the best clinical intervention in this group of smokers, but smoking reduction programmes offer an alternative and effective option.

Establishing the validity and reliability of course evaluation questionnaires

This article uses the case of designing a new course questionnaire to discuss the issues of validity, reliability and diagnostic power in good questionnaire design. Validity is often not well addressed in course questionnaire design as there are no straightforward tests that can be applied to an individual instrument. The authors propose the technique of establishing validity by deriving constructs from naturalistic qualitative research—in this case by interviewing award‐winning teachers about their principles and practices. Analysis of the interview transcripts led to nine principles of good teaching, which were developed into nine questionnaire scales. Reliability was tested with Cronbach’s alpha and with confirmatory factor analysis, as the use of Cronbach’s alpha alone can mask issues of multi‐dimensionality in scales. The concept of diagnostic power as the ability of an instrument to distinguish between related constructs is introduced. This is important in course evaluation questionnaires, as it enables relative strengths and weaknesses to be identified, which makes it possible to advise on remedial action.

Smoking-cessation and adherence intervention among Chinese patients with erectile dysfunction.

BACKGROUND Whether the association between smoking and erectile dysfunction is causal is uncertain. No RCTs have been previously conducted on cessation counseling and additional nicotine replacement therapy (NRT) adherence counseling among smokers with erectile dysfunction. PURPOSE The aim of the study was to determine if smoking-cessation counseling in conjunction with NRT increases quitting and NRT adherence compared to usual care, and if stopping smoking would improve erectile function among Chinese erectile dysfunction patients who smoke. DESIGN An RCT was conducted. Data were collected in 2004-2007 and analyzed in 2008. SETTING/PARTICIPANTS The sample included 719 Chinese adult erectile dysfunction patients who smoked at least 1 cigarette per day, intended to quit smoking within the next 7 days, and would use NRT. INTERVENTIONS Group A1 received 15-minute smoking-cessation and 3-minute NRT adherence counseling at baseline, 1 week, and 4 weeks with free NRT for 2 weeks. Group A2 received the same treatment, except for the adherence counseling. Group B received 10 minutes of quitting advice. All subjects received a self-help quitting booklet at first contact. MAIN OUTCOME MEASURES Self-reported 7-day tobacco abstinence at 6 months, 4-week NRT adherence at 1 month, and improvement in erectile dysfunction condition at 6 months. RESULTS The intervention groups (A1+A2) achieved higher rates of abstinence, both self-reported (23% vs 12.8%, RR=1.79, 95% CI=1.22, 2.62) and biochemically validated (11.4% vs 5.5%, RR=2.07, 95% CI=1.13, 3.77), than the control group. The NRT adherence rate did not differ between Groups A1 and A2 (13.7% vs 12.7%, RR=1.08, 95% CI=0.69, 1.69). An improvement in erectile dysfunction status from baseline to 6 months was associated with self-reported quitting at 6 months but not with intervention status. CONCLUSIONS Although quitting smoking was associated with improvement in erectile dysfunction, this study found significant outcome differences among the means used to achieve smoking cessation. TRIAL REGISTRATION ISRCTN13070778.

A randomized controlled trial of stage‐matched intervention for smoking cessation in cardiac out‐patients

AIM To examine the effectiveness of a stage-matched smoking cessation counselling intervention for smokers who had cardiac diseases. METHODS A total of 1860 Chinese cardiac patients who smoked at least one cigarette in the past 7 days and aged 18 years or above recruited from cardiac out-patient clinics in Hong Kong hospitals were allocated randomly to an intervention group or control group. The intervention group (n = 938) received counselling matched with their stage of readiness to quit by trained counsellors at baseline, 1 week and 1 month. The control group (n = 922) received brief counselling on healthy diet at baseline. The primary outcomes were self-reported 7-day and 30-day point prevalence (PP) of tobacco abstinence at 12 months after baseline. The secondary outcome measures included biochemically validated abstinence at 12-month follow-up, self-reported 7-day and 30-day PP abstinence and reduction of cigarette consumption by 50% at 3 and 6 months. RESULTS By intention-to-treat analysis, the intervention and control groups showed no significant difference in self-reported 7-day PP abstinence (intervention: 26.5% versus control: 25.5%; P = 0.60) and 30-day PP (intervention: 25.4% versus control: 24.2%; P = 0.55), biochemically validated abstinence (intervention: 6.6% versus control: 4.9%; P = 0.14) and overall quit attempts of least 24 hours (intervention: 40.3% versus control: 34.3%; P = 0.007) at the 12-month follow-up, adjusted for the baseline stage of readiness to quit smoking. CONCLUSIONS An intervention, based on the Stages of Change model, to promote smoking cessation in cardiac patients in China failed to find any long-term benefit.

Factor structure and gender invariance of the Chinese General Self-Efficacy Scale among soon-to-be-aged adults

AIM The aim of the study was to examine the factor structure of the Chinese General Self-Efficacy Scale and gender invariance in the structure. BACKGROUND The General Self-Efficacy Scale was developed in 1981 and revised in 1995 to measure peoples beliefs or expectations about their ability to perform tasks on their own across a wide range of demanding/novel situations. While the Chinese version of the General Self-Efficacy Scale has been examined for adolescents and adults from clinical populations, its psychometric properties for community-dwelling Chinese soon-to-be-aged adults, who are in a transitional stage from adulthood to later life, have not been tested. Females have consistently reported a lower general self-efficacy level than males, but it is unclear whether the difference is a result of response bias of the inventory by gender. METHOD A convenience sample of Chinese soon-to-be-aged adults (n = 695) in 28 non-government organizations in Hong Kong completed the survey from March to May 2005. Confirmatory factor analysis was used to test the factor structure and multiple-group confirmatory factor analysis to test the gender invariance of the Chinese version of the General Self-Efficacy Scale. RESULTS The proposed factor structure of the Chinese version of the General Self-Efficacy Scale was an excellent fit to the overall data, and held equally well for both males and females, both genders demonstrating an equivalent pattern of factor loadings. The Cronbach alpha value was high (0·89). CONCLUSION The Chinese version of the General Self-Efficacy is a reliable and valid scale and both genders responded to it using the same framework and metric, thus allowing it to be used with confidence in non-clinical Chinese soon-to-be-aged adult samples.