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1.  Analysis of the Black Racial Identity Attitude scale in a substance-abusing population. 
Racial attitude characteristics of African Americans may have important implications for patient-therapist matching in substance abuse treatment. The Black Racial Identity Attitude Scale (BRIAS) is a questionnaire used to measure racial identity attitudes. This study tested the stability and internal consistency of the BRIAS in an African-American substance-abusing population. This is the first known test of the BRIAS in a clinical population. African-American veterans (n = 53) were administered the BRIAS to test for stability over time and internal consistency. Initial analysis of the instrument revealed that a majority of items were not stable over time. Using the initial results, we removed 26 problematic items. Three modified scales remained, each having marginal test-retest reliability. Two of the modified scales had moderately adequate internal consistency, and the third was minimally adequate. We found that the BRIAS did not demonstrate sufficient internal consistency or stability in this population to adequately identify the constructs of the Nigrescence Racial Identity Development theory of William Cross, Jr. There is a growing recognition of the need to explore the extent of racial, ethnic, and cultural factors in substance abuse behavior and treatment; therefore, we recommend that further attention be directed toward developing an instrument to reliably and accurately measure identity constructs among African-American clinical subjects.
PMCID: PMC2594395  PMID: 12078927
2.  Assessment of a Short Diabetes Knowledge Instrument for Older and Minority Adults 
The Diabetes educator  2013;40(1):68-76.
The purpose of the study was to assess the performance of a short diabetes knowledge instrument (SDKI) in a large multi-ethnic sample of older adults with diabetes and to identify possible modifications to improve its ability to document diabetes knowledge.
Research Design and Methods
A sample of 593 African American, American Indian, and white female and male adults 60 years and older, with diabetes diagnosed at least two years prior, was recruited from eight North Carolina counties. All completed an interview that included a 16-item questionnaire to assess diabetes knowledge. A subsample of 46 completed the questionnaire a second time at a subsequent interview. Item-response analysis was used to refine the instrument to well-performing items. The instrument consisting of the remaining items was subjected to analyses to assess validity and test-retest reliability.
Three items were removed after item-response analysis. Scores for the resulting instrument were lower among minority and older participants, as well as those with lower educational attainment and income. Scores for test-retest were highly correlated.
The SDKI (13 item questionnaire) appears to be a valid and reliable instrument to evaluate knowledge about diabetes. Assessment in a multi-ethnic sample of older adults suggests that this instrument can be used to measure diabetes knowledge in diverse populations. Further evaluation is needed to determine whether or not this instrument can detect changes in knowledge resulting from diabetes education or other interventions.
PMCID: PMC3946961  PMID: 24163359
3.  A New Measure of Fear of Falling: Psychometric Properties of the Fear of Falling Questionnaire Revised (FFQ-R) 
International psychogeriatrics / IPA  2014;27(7):1121-1133.
Although fear of falling is prevalent among older adults recovering from hip fracture, current instruments are inadequate due to focus on specific situations and measurement of self-efficacy rather than fear.
The authors revised and tested a form of the Fear of Falling Questionnaire with three groups of older adults: 405 recovering from hip fracture, 89 healthy community-dwelling, and 42 with severe fear of falling. Test-retest reliability was evaluated in a subsample of 16 hip fracture patients. Internal consistency was compared across all groups Construct validity was established through factor analysis, convergent validity with a measure of fall-related self-efficacy, and discriminant validity with measures of depression and affect.
A revised two-factor, 6-item scale appears to have adequate psychometric properties. Scores were lower among the healthy comparison group relative to the hip fracture and fear of falling groups. Cronbach’s alphas ranged from .72–.83, with test-retest reliability of .82. Correlations with a measure of fall-related self-efficacy were moderate for the hip fracture group (.42) and high with the healthy comparison (.68) and fear of falling (.70) groups. Correlations with depression, negative, and positive affect were low to moderate.
The Fear of Falling Questionnaire - Revised shows promise as a self-report measure of fear of falling, and is one of the first to be tested in older adults recovering from hip fracture. Advantages are that it is global rather than situation-specific and measures fear rather than self-efficacy. Future research on this scale is recommended in other older adult samples for whom fear of falling is relevant.
PMCID: PMC4312554  PMID: 25079081
fear of falling; assessment; hip fracture; questionnaire
4.  Psychometric properties of the Geriatric Anxiety Inventory (GAI) and its short-form (GAI-SF) in a clinical and non-clinical sample of older adults 
International Psychogeriatrics / Ipa  2014;27(7):1089-1097.
The Geriatric Anxiety Inventory is a 20-item geriatric-specific measure of anxiety severity. While studies suggest good internal consistency and convergent validity, divergent validity from measures of depression are weak. Clinical cutoffs have been developed that vary across studies due to the small clinical samples used. A six-item short form (GAI-SF) has been developed, and while this scale is promising, the research assessing the psychometrics of this scale is limited.
This study examined the psychometric properties of GAI and GAI-SF in a large sample of 197 clinical geriatric participants with a comorbid anxiety and unipolar mood disorder, and a non-clinical control sample (N = 59).
The internal consistency and convergent validity with other measures of anxiety was adequate for GAI and GAI-SF. Divergent validity from depressive symptoms was good in the clinical sample but weak in the total and non-clinical samples. Divergent validity from cognitive functioning was good in all samples. The one-factor structure was replicated for both measures. Receiver Operating Characteristic analyses indicated that the GAI is more accurate at identifying clinical status than the GAI-SF, although the sensitivity and specificity for the recommended cutoffs was adequate for both measures.
Both GAI and GAI-SF show good psychometric properties for identifying geriatric anxiety. The GAI-SF may be a useful alternative screening measure for identifying anxiety in older adults.
PMCID: PMC4501012  PMID: 25111285
anxiety disorders; anxiety; questionnaires; geriatric; Geriatric Anxiety Inventory; older adult
5.  The validation of a new measure quantifying the social quality of life of ethnically diverse older women: two cross-sectional studies 
BMC Geriatrics  2011;11:60.
To our knowledge, the available psychometric literature does not include an instrument for the quantification of social quality of life among older women from diverse ethnic backgrounds. To address the need for a tool of this kind, we conducted two studies to assess the initial reliability and validity of a new instrument. The latter was created specifically to quantify the contribution of a) social networks and resources (e.g., family, friends, and community) as well as b) one's perceived power and respect within family and community to subjective well-being in non-clinical, ethnically diverse populations of older women.
In Study 1, we recruited a cross-sectional sample of primarily non-European-American older women (N = 220) at a variety of community locations. Participants were administered the following: a short screener for dementia; a demographic list; an initial pool of 50 items from which the final items of the new Older Women's Social Quality of Life Inventory (OWSQLI) were to be chosen (based on a statistical criterion to apply to the factor analysis findings); the Single Item Measure of Social Support (SIMSS); and the Medical Outcome Study 36-item Short-Form Health Survey (MOS SF-36). Study 2 was conducted on a second independent sample of ethnically diverse older women. The same recruitment strategies, procedures, and instruments as those of Study 1 were utilized in Study 2, whose sample was comprised of 241 older women with mostly non-European-American ethnic status.
In Study 1, exploratory factor analysis of the OWSQLI obtained robust findings: the total variance explained by one single factor with the final selection of 22 items was over 44%. The OWSQLI demonstrated strong internal consistency (α = .92, p < .001), adequate criterion validity with the SIMSS (r = .33; p < .01), and (as expected) moderate concurrent validity with the MOS SF-36 for both physical (r = .21; p < .01) and mental (r = .26; p < .01) quality of life. In order to confirm the validity of the 22-item OWSQLI scale that emerged from Study 1 analyses, we replicated those analyses in Study 2, although using confirmatory factor analysis. The total variance accounted for by one factor was about 42%, again quite high and indicative of a strong single-factor solution. Study 2 data analyses yielded the same strong reliability findings (i.e., α = .92, p < .001). The 22-item OWSQLI was correlated with the SIMSS (r = .27, p < .001) in the expected direction. Finally, correlations with the MOS SF- 36 demonstrated moderate concurrent validity for physical (r = .14; p < .01) and mental (r = .18; p < .01) quality of life, as expected.
The findings of these two studies highlight the potential for our new tool to provide a valid measure of older women's social quality of life, yet they require duplication in longitudinal research. Interested clinicians should consider using the OWSQLI in their assessment battery to identify older women's areas of lower versus higher social quality of life, and should establish the maximization of patients' social quality of life as an important therapeutic goal, as this variable is significantly related to both physical and mental health.
PMCID: PMC3221620  PMID: 21982161
6.  Validity and Reliability of the European Portuguese Version of Neuropsychiatric Inventory in an Institutionalized Sample 
Neuropsychiatric symptoms are very common in dementia and have been associated with patient and caregiver distress, increased risk of institutionalization and higher costs of care. In this context, the neuropsychiatric inventory (NPI) is the most widely used comprehensive tool designed to measure neuropsychiatric Symptoms in geriatric patients with dementia. The aim of this study was to present the validity and reliability of the European Portuguese version of NPI.
A cross-sectional study was carried out with a convenience sample of institutionalized patients (≥ 50 years old) in three nursing homes in Portugal. All patients were also assessed with mini-mental state examination (MMSE) (cognition), geriatric depression scale (GDS) (depression) and adults and older adults functional assessment inventory (IAFAI) (functionality). NPI was administered to a formal caregiver, usually from the clinical staff. Inter-rater and test-retest reliability were assessed in a subsample of 25 randomly selected subjects.
The sample included 166 elderly, with a mean age of 80.9 (standard deviation: 10.2) years. Three out of the NPI behavioral items had negative correlations with MMSE: delusions (rs = -0.177, P = 0.024), disinhibition (rs = -0.174, P = 0.026) and aberrant motor activity (rs = -0.182, P = 0.020). The NPI subsection of depression/dysphoria correlated positively with GDS total score (rs = 0.166, P = 0.038). NPI showed good internal consistency (overall α = 0.766; frequency α = 0.737; severity α = 0.734). The inter-rater reliability was excellent (intraclass correlation coefficient (ICC): 1.00, 95% confidence interval (CI) 1.00 - 1.00), as well as test-retest reliability (ICC: 0.91, 95% CI 0.80 - 0.96).
The results found for convergent validity, inter-rater and test-retest reliability, showed that this version appears to be a valid and reliable instrument for evaluation of neuropsychiatric symptoms in institutionalized elderly.
PMCID: PMC4217749  PMID: 25368697
Behavior disorders; Dementia; Aged; Neuropsychiatric inventory; Validation study
7.  Validation of the Spanish versions of the long (26 items) and short (12 items) forms of the Self-Compassion Scale (SCS) 
Self-compassion is a key psychological construct for assessing clinical outcomes in mindfulness-based interventions. The aim of this study was to validate the Spanish versions of the long (26 item) and short (12 item) forms of the Self-Compassion Scale (SCS).
The translated Spanish versions of both subscales were administered to two independent samples: Sample 1 was comprised of university students (n = 268) who were recruited to validate the long form, and Sample 2 was comprised of Aragon Health Service workers (n = 271) who were recruited to validate the short form. In addition to SCS, the Mindful Attention Awareness Scale (MAAS), the State-Trait Anxiety Inventory–Trait (STAI-T), the Beck Depression Inventory (BDI) and the Perceived Stress Questionnaire (PSQ) were administered. Construct validity, internal consistency, test-retest reliability and convergent validity were tested.
The Confirmatory Factor Analysis (CFA) of the long and short forms of the SCS confirmed the original six-factor model in both scales, showing goodness of fit. Cronbach’s α for the 26 item SCS was 0.87 (95% CI = 0.85-0.90) and ranged between 0.72 and 0.79 for the 6 subscales. Cronbach’s α for the 12-item SCS was 0.85 (95% CI = 0.81-0.88) and ranged between 0.71 and 0.77 for the 6 subscales. The long (26-item) form of the SCS showed a test-retest coefficient of 0.92 (95% CI = 0.89–0.94). The Intraclass Correlation (ICC) for the 6 subscales ranged from 0.84 to 0.93. The short (12-item) form of the SCS showed a test-retest coefficient of 0.89 (95% CI: 0.87-0.93). The ICC for the 6 subscales ranged from 0.79 to 0.91. The long and short forms of the SCS exhibited a significant negative correlation with the BDI, the STAI and the PSQ, and a significant positive correlation with the MAAS. The correlation between the total score of the long and short SCS form was r = 0.92.
The Spanish versions of the long (26-item) and short (12-item) forms of the SCS are valid and reliable instruments for the evaluation of self-compassion among the general population. These results substantiate the use of this scale in research and clinical practice.
PMCID: PMC3896764  PMID: 24410742
Self-compassion; Validation; Spanish; Mindfulness
8.  The WHO-DAS II: Psychometric Properties in the Measurement of Functional Health Status in Adults With Acquired Hearing Loss 
Trends in Amplification  2005;9(3):111-126.
The World Health Organization's (WHO) Disability Assessment Scale II (WHO-DAS II) is a generic health-status instrument firmly grounded in the WHO's International Classification of Functioning, Disability and Health (WHO-ICF). As such, it assesses functioning for six domains: communication, mobility, self-care, interpersonal, life activities, and participation. Domain scores aggregate to a total score. Because the WHO-DAS II contains questions relevant to hearing and communication, it has good face validity for use as an outcome measure for audiologic intervention. The purpose of the present study was to determine the psychometric properties of the WHO-DAS II on a sample of individuals with adult-onset hearing loss, including convergent validity, internal consistency, and test-retest stability. Convergent validity was established by examining correlations between the WHO-DAS II (domain and total scores) and the Abbreviated Profile of Hearing Aid Benefit (APHAB) and the Hearing Aid Handicap for the Elderly (HHIE), two disease-specific measures, as well as with the Short Form-36 for veterans (SF-36V), a second generic measure. Data on all four measures were collected from 380 older individuals with adult-onset hearing loss who were not hearing aid users. The results of the convergent validity analysis revealed that the WHO-DAS II communication domain score was moderately and significantly correlated with scores on the APHAB and the HHIE. WHO-DAS II interpersonal and participation domain scores and the total scores were also moderately and significantly correlated with HHIE scores. These findings support the validity of using the WHO-DAS II for assessing activity limitations and participation restrictions of adult-onset hearing loss. Several WHO-DAS II domain scores and the total score were also significantly and moderately-markedly correlated with scores from the SF-36V. These findings support the validity of the WHO-DAS II as a generic health-status instrument. Internal consistency reliability for all the domain scores was adequate for all but the interpersonal domain. Test-retest stability for all the domain scores was adequate. Critical difference values were calculated for use in clinical application of the WHO-DAS II. From these findings, we concluded that the WHO-DAS II communication, participation, and total scores can be used to examine the effects of adult-onset hearing loss on functional health status. Further work examining the utility of the WHO-DAS II as an outcome measure for hearing aid intervention is warranted.
PMCID: PMC4111522  PMID: 16244758
9.  Adapting the Everyday Discrimination Scale to Medical Settings: Reliability and Validity Testing in a Sample of African American Patients 
Ethnicity & disease  2011;21(4):502-509.
Despite evidence that discrimination within the health care system may play an important role in perpetuating health disparities, instruments designed to measure discrimination within the health care setting have not been adequately tested or validated. Consequently, we sought to test the psychometric properties of a modified version of the Everyday Discrimination scale, adapted for medical settings.
Cross-sectional study.
Academic medical center in Chicago.
Seventy-four African American patients.
Outcome measures
We measured factor analysis, internal consistency, test-retest reliability, convergent validity and discriminant validity.
Seventy-four participants completed the baseline interviews and 66 participants (89%) completed the follow-up interviews. Eighty percent were women. The Discrimination in Medical Settings (DMS) Scale had a single factor solution (eigenvalue of 4.36), a Cronbach’s alpha of 0.89 and test-retest reliability of .58 (P<.0001). The DMS was significantly correlated with an overall measure of societal discrimination (EOD) (r=.51, P<.001) as well as two of its three subscales (unfair: r=−.04, P=.76; discrimination: r=.45, P<0.001; worry: r=−.36, P=.002). The DMS was associated with the overall African American Trust in Health Care Scale (r=.27, P=.02) as well as two key subscales (racism: r=.31, P<.001; disrespect: r=.44, P<.001). The DMS scale was inversely associated with the Social Desirability Scale (r=.18, P=.13). The DMS scale was not correlated with the Center for Epidemiologic Studies Depression Scale (r=.03, P=.80).
The Discrimination in Medical Settings Scale has excellent internal consistency, test-retest reliability, convergent validity and discriminant validity among our sample of African American patients. Further testing is warranted among other racial/ethnic groups.
PMCID: PMC3350778  PMID: 22428358
Health Care Discrimination; Health Care Delivery; Health Disparities; Race/ethnicity; Survey Research
10.  A disease-specific measure of health-related quality of life for use in adults with immune thrombocytopenic purpura: Its development and validation 
No validated disease-specific measures are available to assess health-related quality of life (HRQoL) in adult subjects with immune thrombocytopenic purpura (ITP). Therefore, we sought to develop and validate the ITP-Patient Assessment Questionnaire (ITP-PAQ) for adult subjects with ITP.
Information from literature reviews, focus groups with subjects, and clinicians were used to develop 50 ITP-PAQ items. Factor analyses were conducted to develop the scale structure and reduce the number of items. The final 44-item ITP-PAQ, which includes ten scales [Symptoms (S), Bother-Physical Health (B), Fatigue/Sleep (FT), Activity (A), Fear (FR), Psychological Health (PH), Work (W), Social Activity (SA), Women's Reproductive Health (RH), and Overall (QoL)], was self-administered to adult ITP subjects at baseline and 7–10 days later. Test-retest reliability, internal consistency reliability, construct and known groups validity of the final ITP-PAQ were evaluated.
Seventy-three subjects with ITP completed the questionnaire twice. Test-retest reliability, as measured by the intra-class correlation, ranged from 0.52–0.90. Internal consistency reliability was demonstrated with Cronbach's alpha for all scales above the acceptable level of 0.70 (range: 0.71–0.92), except for RH (0.66). Construct validity, assessed by correlating ITP-PAQ scales with established measures (Short Form-36 v.1, SF-36 and Center for Epidemiologic Studies Depression Scale, CES-D), was demonstrated through moderate correlations between the ITP-PAQ SA and SF-36 Social Function scales (r = 0.67), and between ITP-PAQ PH and SF-36 Mental Health Scales (r = 0.63). Moderate to strong inter-scale correlations were reported between ITP-PAQ scales and the CES-D, except for the RH scale. Known groups validity was evaluated by comparing mean scores for groups that differed clinically. Statistically significant differences (p < 0.01) were observed when subjects were categorized by treatment status [S, FT, B, A, PH, and QoL, perceived effectiveness of ITP treatment [S], and time elapsed since ITP diagnosis [PH].
Results provide preliminary evidence of the reliability and validity of the ITP-PAQ in adult subjects with ITP. Further work should be conducted to assess the responsiveness and to estimate the minimal clinical important difference of the ITP-PAQ to more fully understand the impact of ITP and its treatments on HRQoL.
PMCID: PMC1808052  PMID: 17316442
11.  The Psychometric Properties of the Center for Epidemiologic Studies Depression Scale in Chinese Primary Care Patients: Factor Structure, Construct Validity, Reliability, Sensitivity and Responsiveness 
PLoS ONE  2015;10(8):e0135131.
The Center for Epidemiologic Studies Depression Scale (CES-D) is a commonly used instrument to measure depressive symptomatology. Despite this, the evidence for its psychometric properties remains poorly established in Chinese populations. The aim of this study was to validate the use of the CES-D in Chinese primary care patients by examining factor structure, construct validity, reliability, sensitivity and responsiveness.
Methods and Results
The psychometric properties were assessed amongst a sample of 3686 Chinese adult primary care patients in Hong Kong. Three competing factor structure models were examined using confirmatory factor analysis. The original CES-D four-structure model had adequate fit, however the data was better fit into a bi-factor model. For the internal construct validity, corrected item-total correlations were 0.4 for most items. The convergent validity was assessed by examining the correlations between the CES-D, the Patient Health Questionnaire 9 (PHQ-9) and the Short Form-12 Health Survey (version 2) Mental Component Summary (SF-12 v2 MCS). The CES-D had a strong correlation with the PHQ-9 (coefficient: 0.78) and SF-12 v2 MCS (coefficient: -0.75). Internal consistency was assessed by McDonald’s omega hierarchical (ωH). The ωH value for the general depression factor was 0.855. The ωH values for “somatic”, “depressed affect”, “positive affect” and “interpersonal problems” were 0.434, 0.038, 0.738 and 0.730, respectively. For the two-week test-retest reliability, the intraclass correlation coefficient was 0.91. The CES-D was sensitive in detecting differences between known groups, with the AUC >0.7. Internal responsiveness of the CES-D to detect positive and negative changes was satisfactory (with p value <0.01 and all effect size statistics >0.2). The CES-D was externally responsive, with the AUC>0.7.
The CES-D appears to be a valid, reliable, sensitive and responsive instrument for screening and monitoring depressive symptoms in adult Chinese primary care patients. In its original four-factor and bi-factor structure, the CES-D is supported for cross-cultural comparisons of depression in multi-center studies.
PMCID: PMC4529142  PMID: 26252739
12.  Reliability and Validity of the Perspectives of Support From God Scale 
Nursing research  2010;59(2):102-109.
Existing spiritual support scales for use with cancer survivors focus on the support believed to come from a religious community, clergy, or health care providers.
The objective of this study was to evaluate the reliability and validity of a new measure of spiritual support believed to come from God in older Christian African American cancer survivors.
The Perceived Support From God Scale was administered to 317 African American cancer survivors aged 55–89 years. Psychometric evaluation involved identifying underlying factors, conducting item analysis and estimating reliability, and obtaining evidence on the relationship to other variables or the extent to which the Perceived Support From God Scale correlates with religious involvement and depression.
The Perceived Support From God Scale consists of 15 items in two subscales (Support From God and God’s Purpose for Me). The two subscales explained 59% of the variance. Cronbach’s α coefficients were .94 and .86 for the Support From God and God’s Purpose for Me subscales, respectively. Test–retest correlations were strong, supporting the temporal stability of the instrument. Pearson’s correlations to an existing religious involvement and beliefs scale were moderate to strong. Subscale scores on Support From God were negatively correlated to depression.
Initial support for reliability and validity was demonstrated for the Perceived Support From God Scale. The scale captures a facet of spirituality not emphasized in other measures. Further research is needed to evaluate the scale with persons of other racial/ethnic groups and to explore the relationship of spirituality to other outcome measures.
PMCID: PMC2867661  PMID: 20216012
African Americans; cancer; spiritual support
13.  Religious Participation and DSM-IV Disorders among Older African Americans: Findings from the National Survey of American Life (NSAL) 
This study examined the religious correlates of psychiatric disorders.
The analysis is based on the National Survey of American Life (NSAL). The African American sample of the NSAL is a national representative sample of households with at least one African American adult 18 years or over. This study utilizes the older African American sub-sample (n=837).
Religious correlates of selected measures of lifetime DSM-IV psychiatric disorders (i.e., panic disorder, agoraphobia, social phobia, generalized anxiety disorder, obsessive compulsive disorder, posttraumatic stress, major depressive disorder, dysthymia, bipolar I & II disorders, alcohol abuse/dependence, and drug abuse/dependence) were examined.
Data from 837 African Americans aged 55 years or older are used in this analysis.
The DSM-IV World Mental Health Composite International Diagnostic Interview (WMH-CIDI) was used to assess mental disorders. Measures of functional status (i.e., mobility and self-care) were assessed using the World Health Organization Disability Assessment Schedule-Second Version (WHODAS-II). Measures of organizational, non-organizational and subjective religious involvement, number of doctor diagnosed physical health conditions, and demographic factors were assessed.
Multivariate analysis found that religious service attendance was significantly and inversely associated with the odds of having a lifetime mood disorder.
This is the first study to investigate the relationship between religious participation and serious mental disorders among a national sample of older African Americans. The inverse relationship between religious service attendance and mood disorders is discussed. Implications for mental health treatment underscore the importance of assessing religious orientations to render more culturally sensitive care.
PMCID: PMC2631206  PMID: 19038894
Church Attendance; Depression; Mood Disorder
14.  Assessing Negative Automatic Thoughts: Psychometric Properties of the Turkish Version of the Cognition Checklist 
Beck’s theory of emotional disorder suggests that negative automatic thoughts (NATs) and the underlying schemata affect one’s way of interpreting situations and result in maladaptive coping strategies. Depending on their content and meaning, NATs are associated with specific emotions, and since they are usually quite brief, patients are often more aware of the emotion they feel. This relationship between cognition and emotion, therefore, is thought to form the background of the cognitive content specificity hypothesis. Researchers focusing on this hypothesis have suggested that instruments like the cognition checklist (CCL) might be an alternative to make a diagnostic distinction between depression and anxiety.
The aim of the present study was to assess the psychometric properties of the Turkish version of the CCL in a psychiatric outpatient sample.
Patients and Methods:
A total of 425 psychiatric outpatients 18 years of age and older were recruited. After a structured diagnostic interview, the participants completed the hospital anxiety depression scale (HADS), the automatic thoughts questionnaire (ATQ), and the CCL. An exploratory factor analysis was performed, followed by an oblique rotation. The internal consistency, test-retest reliability, and concurrent and discriminant validity analyses were undertaken.
The internal consistency of the CCL was excellent (Cronbach’s α = 0.95). The test-retest correlation coefficients were satisfactory (r = 0.80, P < 0.001 for CCL-D, and r = 0.79, P < 0.001 for CCL-A). The exploratory factor analysis revealed that a two-factor solution best fit the data. This bidimensional factor structure explained 51.27 % of the variance of the scale. The first factor consisted of items related to anxious cognitions, and the second factor of depressive cognitions. The CCL subscales significantly correlated with the ATQ (rs 0.44 for the CCL-D, and 0.32 for the CCL-A) as well as the other measures of mood severity (all Ps < 0.01). To a great extent, all items of the CCL were able to distinguish the clinical and non-clinical groups, suggesting the scale has high discriminating validity.
The current study has provided evidence that the Turkish version of the CCL is a reliable and valid instrument to assess NATs in a clinical outpatient sample.
PMCID: PMC4733312  PMID: 26834808
Cognitive Aspects; Cognitive Behavior Therapy; Cognition; Cognitive Therapy; Diagnosis
15.  Mental Health Treatment Seeking Among Older Adults with Depression: The Impact of Stigma and Race 
Stigma associated with mental illness continues to be a significant barrier to help seeking, leading to negative attitudes about mental health treatment and deterring individuals who need services from seeking care. This study examined the impact of public stigma (negative attitudes held by the public) and internalized stigma (negative attitudes held by stigmatized individuals about themselves) on racial differences in treatment seeking attitudes and behaviors among older adults with depression.
Random digit dialing was utilized to identify a representative sample of 248 African American and White adults older adults (over the age of 60) with depression (symptoms assessed via the Patient Health Questionnaire-9). Telephone based surveys were conducted to assess their treatment seeking attitudes and behaviors, and the factors that impacted these behaviors.
Depressed older adult participants endorsed a high level of public stigma and were not likely to be currently engaged in, nor did they intend to seek mental health treatment. Results also suggested that African American older adults were more likely to internalize stigma and endorsed less positive attitudes toward seeking mental health treatment than their White counterparts. Multiple regression analysis indicated that internalized stigma partially mediated the relationship between race and attitudes toward treatment.
Stigma associated with having a mental illness has a negative influence on attitudes and intentions toward seeking mental health services among older adults with depression, particularly African American elders. Interventions to target internalized stigma are needed to help engage this population in psychosocial mental health treatments.
PMCID: PMC2875324  PMID: 20220602
Stigma; Depression; Treatment; Aging
16.  Development of the Computer-Adaptive Version of the Late-Life Function and Disability Instrument 
Having psychometrically strong disability measures that minimize response burden is important in assessing of older adults.
Using the original 48 items from the Late-Life Function and Disability Instrument and newly developed items, a 158-item Activity Limitation and a 62-item Participation Restriction item pool were developed. The item pools were administered to a convenience sample of 520 community-dwelling adults 60 years or older. Confirmatory factor analysis and item response theory were employed to identify content structure, calibrate items, and build the computer-adaptive testings (CATs). We evaluated real-data simulations of 10-item CAT subscales. We collected data from 102 older adults to validate the 10-item CATs against the Veteran’s Short Form-36 and assessed test–retest reliability in a subsample of 57 subjects.
Confirmatory factor analysis revealed a bifactor structure, and multi-dimensional item response theory was used to calibrate an overall Activity Limitation Scale (141 items) and an overall Participation Restriction Scale (55 items). Fit statistics were acceptable (Activity Limitation: comparative fit index = 0.95, Tucker Lewis Index = 0.95, root mean square error approximation = 0.03; Participation Restriction: comparative fit index = 0.95, Tucker Lewis Index = 0.95, root mean square error approximation = 0.05). Correlation of 10-item CATs with full item banks were substantial (Activity Limitation: r = .90; Participation Restriction: r = .95). Test–retest reliability estimates were high (Activity Limitation: r = .85; Participation Restriction r = .80). Strength and pattern of correlations with Veteran’s Short Form-36 subscales were as hypothesized. Each CAT, on average, took 3.56 minutes to administer.
The Late-Life Function and Disability Instrument CATs demonstrated strong reliability, validity, accuracy, and precision. The Late-Life Function and Disability Instrument CAT can achieve psychometrically sound disability assessment in older persons while reducing respondent burden. Further research is needed to assess their ability to measure change in older adults.
PMCID: PMC3670156  PMID: 22546960
Function; Disability; Computer-adaptive testing; Activity; Participation
17.  Late-life Depression in Older African Americans: A Comprehensive Review of Epidemiological and Clinical Data 
The population of older African Americans is expected to triple by 2050, highlighting the public health importance of understanding their mental health needs. Despite evidence of the negative impact of late-life depression, less is known of how this disorder affects the lives of older African Americans. Lack of studies focusing on how depression presents in older African Americans and their subsequent treatment needs lead to a gap in epidemiologic and clinical knowledge for this population. In this review, we aim to present a concise report of prevalence, correlates, course, outcomes, symptom recognition, and treatment of depression for these individuals.
We performed a literature review of English-language articles identified from PubMed and Medline published between January 1990 and June 2012. Studies included older adults and contained the key words “geriatric depression in African Americans,” “geriatric depression in Blacks,” and geriatric depression in minorities.”
Although in most studies older African Americans had higher or equivalence prevalence of depression compared to Caucasian Americans, we also found lower rates of recognition of depression and treatment. Many studies reported worse outcomes associated for depression among older African Americans compared older Caucasians.
Serious racial and ethnic disparities persist in the management of older African Americans with depression. Understanding their unmet needs and improving depression care for these individuals is necessary to reduce these disparities.
PMCID: PMC3674152  PMID: 23225736
Late-life Depression; Race; African Americans
18.  Psychometric Properties of Positive and Negative Affect Schedule (PANAS) Original and Short Forms in an African American Community Sample 
Journal of affective disorders  2013;151(3):942-949.
The Positive and Negative Affect Schedule (PANAS) has been widely used as a self-report measure of affect in community and clinical contexts. However, evaluations of the psychometric properties of PANAS scores have been limited in diverse ethnic groups. Several short forms of the PANAS have also been proposed, but very little is known about the psychometric properties of these versions.
The present study investigated the psychometric properties, including the factor structure of the original PANAS and two short forms in an African American community sample (N = 239). Descriptive, internal consistency reliability, factorial validity, and measurement invariance analyses were conducted.
All PANAS subscales from the original and short forms had adequate internal consistency. For the original PANAS, the model specifying three correlated factors (Positive Affect, Afraid, Upset) with correlated uniquenesses from redundant items provided the best fit to the data. However, the two-factor model (Positive Affect, Negative Affect) with correlated uniquenesses was also supported. For both short forms, the two-factor model with correlated uniquenesses fit the data best. Factors from all forms were generally invariant across age and gender, although there was some minor invariance at the item level.
Participants were from a limited geographic area and one ethnic group. Indicators of anxiety, depression, and cultural characteristics were not measured.
The factor structure was replicated, suggesting no immediate concerns regarding the valid interpretation of PANAS scores. The results support the reliability and validity of the PANAS and its short forms for use among African Americans.
PMCID: PMC3934411  PMID: 24051099
PANAS; short form; African American; psychometrics; confirmatory factor analysis
The Journal of urology  2008;179(4):1449-1454.
To determine incidence and predictors of incident urinary incontinence over 3 years in community-dwelling older adults.
A population-based, prospective cohort study was conducted with a random sample of Medicare beneficiaries, stratified to be 50% African American, 50% men, and 50% rural. In-home baseline assessment included standardized questionnaires and short physical performance battery. Three annual follow-up interviews were conducted by telephone. Incontinence was defined as any degree of incontinence occurring at least once a month in the past 6 months.
Participants were 490 women and 496 men, age 65 to 106 years (mean=75 years). Prevalence of incontinence at baseline was 41% in women and 27% in men. Three-year incidence of incontinence was 29% (84/290) in women and 24% (86/363) in men. There were no differences by race in prevalent or incident incontinence. In multivariable logistic regression models for women, significant independent baseline predictors of new incontinence included: stroke (OR 3.4, p=.011), incontinence < monthly (OR 3.3, p=.001), past or current post-menopausal estrogen (OR 2.3, p<.006), slower time to stand from a chair 5 times (OR 1.3, p<.045), and higher Geriatric Depression Scale Score (OR 1.2, p=.016). For men, significant independent baseline predictors of new incontinence included: incontinence < monthly (OR 4.2, p<.001) and lower score on the composite Physical Performance Score (OR 1.2, p<.001).
Prevalence of incontinence among community-dwelling older adults was high with an additional 29% of women and 24% of men reporting incident incontinence over 3 years of follow-up. Infrequent incontinence is a strong risk factor for developing at least monthly incontinence in both men and women.
PMCID: PMC2999469  PMID: 18295279
Urinary Incontinence; Epidemiology; Incidence; African Americans
20.  Impact of Alzheimer’s Disease on Caregiver Questionnaire: internal consistency, convergent validity, and test-retest reliability of a new measure for assessing caregiver burden 
There is a lack of validated instruments to measure the level of burden of Alzheimer’s disease (AD) on caregivers. The Impact of Alzheimer’s Disease on Caregiver Questionnaire (IADCQ) is a 12-item instrument with a seven-day recall period that measures AD caregiver’s burden across emotional, physical, social, financial, sleep, and time aspects. Primary objectives of this study were to evaluate psychometric properties of IADCQ administered on the Web and to determine most appropriate scoring algorithm.
A national sample of 200 unpaid AD caregivers participated in this study by completing the Web-based version of IADCQ and Short Form-12 Health Survey Version 2 (SF-12v2™). The SF-12v2 was used to measure convergent validity of IADCQ scores and to provide an understanding of the overall health-related quality of life of sampled AD caregivers.
The IADCQ survey was also completed four weeks later by a randomly selected subgroup of 50 participants to assess test-retest reliability. Confirmatory factor analysis (CFA) was implemented to test the dimensionality of the IADCQ items. Classical item-level and scale-level psychometric analyses were conducted to estimate psychometric characteristics of the instrument. Test-retest reliability was performed to evaluate the instrument’s stability and consistency over time.
Virtually none (2%) of the respondents had either floor or ceiling effects, indicating the IADCQ covers an ideal range of burden. A single-factor model obtained appropriate goodness of fit and provided evidence that a simple sum score of the 12 items of IADCQ can be used to measure AD caregiver’s burden. Scales-level reliability was supported with a coefficient alpha of 0.93 and an intra-class correlation coefficient (for test-retest reliability) of 0.68 (95% CI: 0.50–0.80). Low-moderate negative correlations were observed between the IADCQ and scales of the SF-12v2.
The study findings suggest the IADCQ has appropriate psychometric characteristics as a unidimensional, Web-based measure of AD caregiver burden and is supported by strong model fit statistics from CFA, high degree of item-level reliability, good internal consistency, moderate test-retest reliability, and moderate convergent validity. Additional validation of the IADCQ is warranted to ensure invariance between the paper-based and Web-based administration and to determine an appropriate responder definition.
PMCID: PMC4265347  PMID: 25186634
Alzheimer’s disease; Caregivers; Burden; Psychometrics; Questionnaire
21.  Psychosocial predictors of depression among older African American cancer patients 
Oncology nursing forum  2013;40(4):394-402.
To determine whether psychosocial factors predict depression among older African American cancer patients.
A descriptive correlational study.
Outpatient oncology clinic of NCI designated Cancer Center in Southeastern U.S.
African American cancer patients aged 50 and over.
Fisher’s Exact and Wilcoxon Rank Sum tests were used to evaluate differences between patients who were possibly depressed (Geriatric Depression Scale) or not. Multivariate linear regression statistics were used to identify the psychosocial factors that predicted higher depression scores. Education and gender were included as covariates.
Main Variables
Religiosity, emotional support, collectivism, perceived stigma and depression.
African American cancer patients (n=77) were on average a median age of 58 years (IQR = 55–65), a majority were well-educated, insured, religiously affiliated, and currently in treatment. Participants in the lowest income category, not married, and male gender had higher depression scores. The multivariable model consisting of organized religion, emotional support, collectivism, education, and gender explained 52% (adjusted R2) of the variation in depression scores. Stigma became insignificant in the multivariable model.
Psychosocial factors are important predictors of depression. For these participants, emotional support and organized religious activities may represent protective factors against depression, while collectivism may increase their risk.
Nurses need to be especially aware of the potential psychological strain for patients with collectivist values, experienced stigma, disruptions in church attendance and lack of emotional support. Further, these treatment plans for these patients should ensure that family members are knowledgeable about cancer, its treatment and side effects so they are empowered to meet the needs for support of the African American cancer patient.
PMCID: PMC3753674  PMID: 23803271
depression; stigma; religion; collectivism; social support; African American cancer patients
22.  Psychometric Properties of the Center for Epidemiologic Studies Depression Scale in African-American and Black Caribbean Adults 
Issues in mental health nursing  2012;33(10):687-696.
A 12-item version of the 20-item Center for Epidemiological Studies-Depression (CESD) Scales was not validated in Black U.S. adults but demonstrated strong psychometrics in other populations. Using data from the National Survey of American Life (n=4,815), the psychometric properties of the scale were tested in African-American and Black Caribbean adults. When compared with the DSM-IV-TR criteria for Major Depressive Disorder and Dysthymia, most items focus on depressed mood, providing evidence for content validity. Construct validity was questionable in African-American and Black Caribbean men. The CESD scores of African-American men who met the DSM-IV-TR criteria for Dysthymia were not significantly different than African-American men who did not (t=1.9, p=.109). The CESD scores of Black-Caribbean men who met the DSM-IV-TR criteria for MDD were not significantly different than Black-Caribbean men who did not (t=1.6, p=.198), and none of the Black-Caribbean men met the DSM-IV-TR criteria for Dysthymia. All groups had item-to-total correlations and inter-item correlations below 0.30 with the item “I felt like everything I did was an effort”. African-American and Black Caribbean men also had item-to-total correlations and inter-item correlations below 0.30 with the item “I felt that I was just as good as other people”. After eliminating these items, the alpha for the remaining 11 items was 0.80 and 0.76 in African-American and Black Caribbean women respectively. The alpha for the remaining 10 items was 0.73 in African-American and Black Caribbean men. The cut-off score was nine for the 11-item CESD and eight for the 10-item CESD.
PMCID: PMC4124820  PMID: 23017046
23.  Combined Medication and CBT for Generalized Anxiety Disorder with African American Participants: Reliability and Validity of Assessments and Preliminary Outcomes 
Behavior therapy  2014;45(4):495-506.
Using data from a study of combined cognitive behavioral therapy (CBT) and venlafaxine XR in the treatment of generalized anxiety disorder (GAD), the current article examines the reliability and convergent validity of scales, and preliminary outcomes, for African American compared to European American patients. Internal consistency and short-term stability coefficients for African Americans (n=42) were adequate and similar or higher compared to those found for European Americans (n=164) for standard scales used in GAD treatment research. Correlations among outcome measures among African Americans were in general not significantly different for African Americans compared to European Americans. A subset of patients with DSM-IV–diagnosed GAD (n = 24 African Americans; n = 52 European Americans) were randomly selected to be offered the option of adding 12 sessions of CBT to venlafaxine XR treatment. Of those offered CBT, 33.3% (n = 8) of the African Americans, and 32.6% (n = 17) of the European Americans accepted and attended at least one CBT treatment session. The outcomes for African Americans receiving combined treatment were not significantly different from European Americans receiving combined treatment on primary or secondary efficacy measures.
PMCID: PMC4260926  PMID: 24912462
Generalized Anxiety Disorder; Cognitive-Behavioral Therapy; venlafaxine; combined treatment; African American
24.  Are Gold Standard Depression Measures Appropriate for Use in Geriatric Cancer Patients? A Systematic Evaluation of Self-Report Depression Instruments Used With Geriatric, Cancer, and Geriatric Cancer Samples 
Journal of Clinical Oncology  2009;28(2):348-356.
Geriatric issues in cancer are becoming prominent. Depression is a significant concern for both the elderly and patients with cancer, yet identifying depression in these patients is difficult and often leads to under-recognition. We conducted a systematic review to determine which depression instruments are appropriate for use in geriatric patients with cancer.
We identified the most commonly used self-report depression instruments. We then used the criteria established in the US Food and Drug Administration Draft Guidance on Patient-Reported Outcome Measures to determine the extent of validation evidence of these measures in geriatric cancer populations. Finally, we determined which instruments captured depressive symptoms that are common among elderly patients with cancer.
Eight measures were selected as the most commonly used instruments. These were the Beck Depression Inventory-II, Brief Symptom Inventory-18, Center for Epidemiologic Studies–Depression Scale, Geriatric Depression Scale-15, Hospital Anxiety and Depression Scale, Patient Health Questionnaire-9, Profile of Mood States–Short Form, and Zung Self-Rating Depression Scale. Many have been validated for use with geriatric adults and patients with cancer; however, data addressing content validity and responder definition were lacking. To date, there is no validation information for geriatric patients with cancer. Furthermore, symptom profile analysis revealed that these measures do not identify many symptoms signaling depression in geriatric patients with cancer.
The validation evidence for use of common depression instruments in geriatric patients with cancer is lacking. This, and the possibility that these measures may not assess common depressive symptoms in geriatric patients with cancer, questions the adequacy of these scales in this population.
PMCID: PMC2815722  PMID: 19996030
25.  Reliability and validity of three questionnaires measuring context-specific sedentary behaviour and associated correlates in adolescents, adults and older adults 
Reliable and valid measures of total sedentary time, context-specific sedentary behaviour (SB) and its potential correlates are useful for the development of future interventions. The purpose was to examine test-retest reliability and criterion validity of three newly developed questionnaires on total sedentary time, context-specific SB and its potential correlates in adolescents, adults and older adults.
Reliability and validity was tested in six different samples of Flemish (Belgium) residents. For the reliability study, 20 adolescents, 22 adults and 20 older adults filled out the age-specific SB questionnaire twice. Test-retest reliability was analysed using Kappa coefficients, Intraclass Correlation Coefficients and/or percentage agreement, separately for the three age groups. For the validity study, data were retrieved from 62 adolescents, 33 adults and 33 older adults, with activPAL™ as criterion measure. Spearman correlations and Bland-Altman plots (or non-parametric approach) were used to analyse criterion validity, separately for the three age groups and for weekday, weekend day and average day.
The test-retest reliability for self-reported total sedentary time indicated following values: ICC = 0.37-0.67 in adolescents; ICC = 0.73-0.77 in adults; ICC = 0.68-0.80 in older adults. Item-specific reliability results (e.g. context-specific SB and its potential correlates) showed good-to-excellent reliability in 67.94 %, 68.90 % and 66.38 % of the items in adolescents, adults and older adults respectively. All items belonging to sedentary-related equipment and simultaneous SB showed good reliability. The sections of the questionnaire with lowest reliability were: context-specific SB (adolescents), potential correlates of computer use (adults) and potential correlates of motorized transport (older adults). Spearman correlations between self-reported total sedentary time and the activPAL™ were different for each age group: ρ = 0.02-0.42 (adolescents), ρ = 0.06-0.52 (adults), ρ = 0.38-0.50 (older adults). Participants over-reported total sedentary time (except for weekend day in older adults) compared to the activPAL™, for weekday, weekend day and average day respectively by +57.05 %, +46.29 %, +53.34 % in adolescents; +40.40 %, +19.15 %, +32.89 % in adults; +10.10 %, −6.24 %, +4.11 % in older adults.
The questionnaires showed acceptable test-retest reliability and criterion validity. However, over-reporting of total SB was noticeable in adolescents and adults. Nevertheless, these questionnaires will be useful in getting context-specific information on SB.
Electronic supplementary material
The online version of this article (doi:10.1186/s12966-015-0277-2) contains supplementary material, which is available to authorized users.
PMCID: PMC4574538  PMID: 26381488
Adolescents; Adults; Older adults; Questionnaire; Validity; Reliability; Sedentary behaviour

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