中国人亚健康量表的统计建模研究
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摘要
本研究的目的是要研制适合中国20至60岁人群的亚健康状态测量量表(Chinese Sub-health Scale,CSHS)。本文经过四个阶段的研究,采用传统和现代统计建模技术研制出中国人亚健康量表(CSHS-4)。量表包括三个领域(躯体表现、心理表现和社会适应)、13个方面(疲劳、消化、睡眠、不适、疼痛、机能失调、免疫力、便秘、抑郁焦虑、记忆力、压力、满意感、性生活)、47个条目。现有样本数据(数据2)分析结果表明量表有良好的信度和效度;验证性因子分析结果支持三因子(躯体表现、心理表现、社会适应)模型,建议将性生活领域归属为社会适应领域的一个新的方面。
第一个阶段研究是提出中国人亚健康状态初始调查问卷(CSHS-1)。课题组首先研究确定亚健康的概念及范畴,并将其分解,初步确定中国人亚健康状态调查问卷的内容结构,包括四个领域(躯体表现、心理表现、社会适应性及生活方式),13个方面(疲劳、消化、睡眠、机能失调、免疫力、衰老、抑郁、焦虑、安全感、学习和记忆力、社会适应、生活方式、性生活)。在文献回顾的基础上,参考国际上公认的健康测量量表,提出中国人亚健康状态调查问卷的条目池。采用Delphi法进行条目初筛,保留重要的、敏感性高、独立性强、代表性好、具有可操作性和可接受性的条目。经过60位文化程度中等人士的预试和条目修订,形成了中国人亚健康状态初始调查问卷(CSHS-1),包括四个领域(躯体表现、心理表现、社会适应和生活方式)、13个方面(疲劳、消化、睡眠、机能失调、免疫力、衰老、抑郁、焦虑、安全感、学习和记忆、社会适应、生活方式、性生活),共74个条目。
第二个阶段的研究是进行预调查,筛选条目,形成中国人亚健康状态正式调查问卷(CSHS-2)。课题组采用第一阶段形成的初始调查问卷(CSHS-1)进行预调查,预调查在上海、南通、河北、河南、云南五个研究中心展开,采用整群随机抽样方法确定调查对象,共收回有效调查问卷544份。采用频数分析、离散趋势分析、相关分析、探索性因子分析、聚类分析和内部一致性分析筛选条目,结果保留46个条目。在此基础上,课题组对问卷内容进行调整,新增32个条目,形成中国人亚健康状态的正式调查问卷(CSHS-2),包括4个领域(躯体表现、心理表现、社会适应和性生活)、15个方面(疲劳、消化、睡眠、机能失调、免疫力、不适、疼痛、便秘、抑郁、焦虑、安全感、学习和记忆力、压力、满意感、性生活),共78个条目。
第三个阶段的研究是进行现场调查,进行量表条目筛选,形成中国人亚健康量表(CSHS-3)。课题组使用第二阶段形成的正式调查问卷(CSHS-2),采取整群随机抽样方法,对上海市两个体检中心的856名调查对象进行了现场调查,经过数据整理,确定462例合格样本数据(数据1)用于量表条目筛选。筛选量表条目采用的统计学方法包括:频数分布、条目分析、内部一致性分析和探索性因子分析。频数分析主要考核量表各条目得分的天花板和地板效应(ceiling effect & floor effect),删除天花板和地板效应较大的条目;条目分析主要考核量表中每个条目对的贡献大小,计算条目得分与量表总分,以及条目得分与所属方面得分的相关系数,删除相关系数过小,或与其他方面相关系数较大的条目;内部一致性分析采用Cronbachα系数考核量表总的、各领域和各方面的内部一致性。如果去除某一条目后,相应方面的Cronbachα系数有较大升高,则删除该条目;采用探索性因子分析,根据各条目在因子上的载荷大小筛选条目。如果条目在单个因子上的载荷小于0.35,或在两个或两个以上因子上的载荷均超过0.35,则删除该条目。经过上述分析,如果一个条目被两种或两种以上方法建议删除,则删除该条目。结果共删除23个条目,保留55个条目。
相关分析结果显示:反映抑郁和焦虑两个方面的条目有较强的关联关系,建议将两个方面合并成一个新的方面(抑郁焦虑),该结果与因子分析结果一致,即反映抑郁和焦虑的条目在同一个因子上载荷较大。研究结果确定中国人亚健康量表(CSHS-3)包括4个领域(躯体表现、心理表现、社会适应、性生活)、13个方面(疲劳、消化、睡眠、不适、疼痛、机能失调、免疫力、便秘、抑郁焦虑、记忆力、压力、满意感、性生活)、共55个条目。
第四个阶段研究是进行现场调查,考核量表的信度和效度,验证量表结构,进一步完善量表。课题组采用第三阶段形成的调查问卷(CSHS-3),采用整群随机抽样的方法,对全国9个地区的10000例调查对象进行现场调查。调查地区包括上海、西安、扬州、昆明、泸州、石家庄、郑州、河南、芜湖,要求各中心在确定调查对象时考虑被调查对象在性别、年龄和职业等方面的均衡。由于现场调查正在进行中,本文仅对已经收回的四个地区(上海、西安、河南、河北)的876例被调查对象的数据(数据2)进行分析。从内部一致性、重测信度和分半信度三个方面考核量表信度;从结构效度、标准关联效度和区分效度三个方面考核量表的效度;采用验证性因子分析考核量表结构是否与假设的理论模型一致。
内部一致性分析结果显示:量表总的Cronbachα系数为0.93;除性生活领域(仅有2个条目组成)外,其他三个领域的Cronbachα系数在0.83-0.93之间;除便秘、记忆力和性生活方面(仅有2个条目)外,其他10个方面的Cronbachα系数在0.67-0.84之间,结果表明量表有较好的内部一致性。重复测量分析结果显示:量表总的重测信度为0.91;4个领域的重测信度在0.76(性生活)到0.93(躯体表现)之间;13个方面的重测信度在0.63(疲劳)到0.87(便秘)之间,结果表明量表测量结果具有较好的稳定性和一致性。分半信度分析结果显示:量表总的分半信度为0.95;除性生活领域(仅有2个条目)外,其他3个领域的分半信度分别为0.92(躯体表现)、0.88(心理表现)和0.83(社会适应),结果表明量表有较好的分半信度。
结构效度分析结果显示:领域得分与总分之间的Spearman相关系数在0.32(性生活)-0.93(躯体表现)之间;方面得分与量表总分之间的Spearman相关系数在0.32(性生活)-0.77(抑郁焦虑)之间;除性生活领域(只包括1个方面)外,其他方面与所属领域间的Spearman相关系数均在0.56(便秘)-0.97(压力)之间,分析结果表明,性生活领域结构效度较低,其他领域和方面均有较好的结构效度。标准关联效度分析结果表明:量表各领域和方面与主观健康得分之间有较弱的标准关联效度。区分效度分析结果表明,55个条目均有很强的区分健康人、亚健康人和病人的能力,也具有很强的区分量表总分较高(上30%)和较低(下30%)人群的能力。
验证性因子分析分别从领域和整个量表的角度验证量表结构的优劣。躯体表现领域验证性因子分析结果表明:条目F602和F903未标准化负荷异常,F302在所属方面(潜变量)上的因子负荷小于0.35,建议删除这3个条目。删除条目F302、F602、F903和F901(因为便秘方面仅剩下1个条目)后,躯体表现领域验证性因子分析结果表明模型拟合良好:NNFI =0.955,RMSEA =0.0641,CFI =0.961,参数估计值比较合理且有统计学意义(t>2)。心理表现领域验证性因子分析结果表明模型拟合良好:NNFI =0.968,RMSEA =0.0832,CFI =0.978;各条目因子负荷在0.490-0.834之间,且有统计学意义(t>2);所有测量方程的决定系数在0.314(F1201)-0.860(F1202)之间。社会适应领域的验证性因子分析结果显示:经过模型修正,模型拟合良好:NNFI =0.966,RMSEA =0.0682,CFI =0.973;参数估计合理且有统计学意义。
整个量表结构的验证性因子分析结果显示:条目F1402、F18、F2002因协方差为负值,建议删除,F2001因该方面仅剩下一个条目,暂时不考虑;删除F1402、F18、F2002、F2001后,验证性因子分析结果显示模型拟合良好:NNFI =0.915,RMSEA =0.0866,CFI =0.915;参数估计合理,且有统计学意义。将各领域得分作为观测变量,比较亚健康的三因子(躯体表现、心理表现、社会适应)模型和四因子(躯体表现、心理表现、社会适应和性生活)模型的优劣,分析结果支持三因子结构模型,建议将反映性生活的方面归属到社会适应领域,作为社会适应领域的一个方面。
最后,获得修正后的中国人亚健康量表(CSHS-4),包括3个领域(躯体表现、心理表现和社会适应)、13个方面(疲劳、消化、睡眠、不适、疼痛、机能失调、免疫力、便秘、抑郁焦虑、记忆力、压力、满意感、性生活)、共47个条目。
The overall aim of the present study was to develop a sub-heath scale that is suitable for Chinese aged from 20 to 60 years old (the Chinese Sub-heath Scale, CSHS). This paper describes the development and validation of CSHS. After four phases of researches, we have proposed the CSHS-4, which includes 47 items, 13 facets (fatigue, digestion, sleep, indisposition, ache, dysfunction, immunity, constipation, depression and anxiety, memory, pressure, satisfaction, sex behavior) and 3 domains (physical, psychological and social accommodation) with the use of classical and contemporary statistical technique.
The analytic results of the present field data (data2) show that the CSHS-3 is a reliable measuring instrument with good reliability and validity. The confirmatory factor analysis of CSHS-3 suggests that the 3 domain (physical, psychological and social accommodation) solution is appropriate and sex domain is recommended to be a new facet of social accommodation domain.
The goal of the first phase study was to generate the initial SCHS questionnaire (CSHS-1). First of all, the research group worked to determine the concept and scope of sub-health and decompose it into four domains (physical, psychological, social accommodation and life style), 13 facets (fatigue, digestion, sleep, indisposition, immunity, aging, depression, anxiety, feeling of safety, learning and memory, social accommodation, life style, sex behavior). A draft item pool of SCHS questionnaire was developed based on the literature review and referring the wildly used measures for assessing health-related issues. These items were primarily screened by experts using Delphi technique and the items with more importance, high sensitivity, stronger independence, better representation, maneuverability and acceptability were reserved. After being pre-tested and modified by 60 middle-degree educated subjects, the initial questionnaire (CSHS-1) was determined, which covers 4 domains (physical, psychological, social accommodation and life style), 13 facets (fatigue, digestion, sleep, dysfunction, immunity, aging, depression, anxiety, feeling of safety, learning and memory, social accommodation, life style, sex behavior), and includes 74 items totally.
The aim of the second phase research was to conduct pretest, select items and then generate the formal questionnaire of CSHS (CSHS-2). A pre-test was carried out in 5 centers nationwide, they were located in Shanghai, Nantong Hubei, Hunan and Yunnan. The instrument applied was the CSHS-1 questionnaire proposed in phaseⅠ. The participants were determined by group randomized sampling method. 544 valid questionnaires were selected. Items were tested and reduced by 6 methods, frequency analysis, dispersion trend analysis correlation analysis, exploratory factor analysis, cluster analysis and internal consistency analysis. As a result 46 items were reserved. Based on this result, the questionnaire was adjusted and 32 additional items were added to form the formal CSHS questionnaire (CSHS-2), which includes 4 domains: (physical, psychological, social accommodation and sex behavior), 15 facets (fatigue, digestion, sleep, dysfunction, immunity, indisposition, ache, constipation, depression, anxiety, feeling of safety, learning and memory, pressure, satisfaction and sex behavior), and 78 items.
In the third phase research, a field research was conducted to collect data on the CSHS items for the purpose of item testing and reduction and proposing the CSHS-3. The CSHS-2 proposed in phaseⅡwas applied to 856 volunteers from 2 medical examination centers of Shanghai. 462 valid questionnaires were used as the dataset (data1) to test and reduce items after data processing. The statistical methods applied in item testing and item reduction were frequency analysis, item analysis, internal consistency analysis and exploratory factor analysis. Frequency analysis was used mainly for the purpose of checking ceiling and floor effect of item responds. The items with more than 20% ceiling or floor effect should be excluded. Item analysis was undertaken to examine the contributions of individual items within the scale. Item-total and item-facet score correlations were calculated, items of smaller coefficients and/or of larger correlation coefficients with other facets were excluded. Internal consistency of total, domains and facets was assessed using Cronbachαcoefficient. The item should be excluded if the corresponding facet’s Cronbachαcoefficient greatly increases after deleting the item. Exploratory factor analysis was used for the purpose of selecting items according to their loading on each factor. The item should be excluded if the item has a factor loading of less than 0.35 or greater than 0.35 on two or two more factors. Through the analysis of the four methods mentioned above, the items should be excluded if they were recommended to be deleted by the results of two or more methods. Thus, 55 items are reserved while 23 items are deleted. The result of correlation analysis shows that the items of depression and anxiety facet are recommended to be merged as a new facet called depression and anxiety facet due to high correlation, as recommended by the result of exploratory factor analysis, the items of depression and anxiety facet have high loading on the same factor. Finally, the refined CSHS questionnaire (CSHS-3) is composed of 4 domains 4 domains(physical, psychological, social accommodation, sex behavior), 13 facets(fatigue, digestion, sleep, indisposition, ache, dysfunction, immunity, constipation, depression and anxiety, feeling of safety, memory, pressure, satisfaction, sex) and 55 items.
A large scale field research was conducted in phaseⅣfor the purpose of assessing validity and reliability of CSHS-3 proposed in phaseⅢ. The participants were determined by group randomized sampling method. 9 centers nationwide involved in the research, they were located in Shanghai, Xian, Yangzhou, Kunming, Luzhou, Shijiazhuang, Zhengzhou, Henan and Wuhu. The CSHS questionnaire proposed in phaseⅢwas applied to 10000 participants.
The centers were requested to consider the balance of gender, age and occupation of volunteers when they were recruited. The presented 876 questionnaires were only from 4 sites (Shanghai, Xian, Henan and Hebei) because the field research is on going now. Internal consistency, test-retest reliability and split-half reliability were used to check the reliability of CSHS-3. Construct validity, criteria-related validity and discriminant validity were used to examine the validity of CSHS-3. Confirmatory factor analysis was conducted with LISREL8.53 to test if the scale construction was consistent to that of hypothesized model.
The result of internal consistency analysis showed a better internal consistency of CSHS-3. The Cronbachαcoefficient for total score was 0.93. Except sex behavior domain (includes two items); Cronbachαcoefficient for other three domain score ranged from 0.83 to 0.93 and Cronbachαcoefficient for 10 facet score (except constipation, memory and sex behavior facet that includes two items) ranged from 0.67 to 0.84. The result of test-retest analysis shows good test-retest reliability. Correlation coefficient for the total score was 0.91, for 4 domains ranged from 0.76 (sex behavior) to 0.93 (physical), for 13 facets ranged from 0.63 (fragile) to 0.87 (constipation). The result of split-half reliability analysis indicates a high correlation between halves. The split-half correlation coefficient for CSHS-3 was 0.95, for physical domain (0.92), psychological domain (0.88) and for social accommodation domain (0.83). The result of construct validity analysis showed that most domains and facets had better construct validity except sex behavior domain. The Spearman correlation between domain score and total score ranged from 0.32 (sex behavior) to 0.73 (physical domain). The Spearman correlation between facet scores and total score ranged from 0.32 (sex behavior) to 0.77 (depression and anxiety). Except that the sex behavior domain had single facet, The Spearman correlation between facet score and domain score ranged from 0.56 (constipation) to 0.97 (Pressure). The result of criteria-related validity analysis showed a weak criteria-related validity. The Spearman correlation between domain/facet score and subjective health score ranged between 0.10 (sex behavior) to 0.27 (physical domain). The result of Discriminant validity analysis showed that the 55 items had strong Discriminant validity. Each of the 55 items had statistically significant difference among healthy, sub-healthy and patient groups, and also between the upper 30% and the lower 30% total score groups. Three domains and the whole CSHS-3 were tested using confirmatory factor analysis (CFA). The result of physical domain showed that three items F602, F903 and F302 were suggested to be excluded because of abnormal parameters and lower factor loading on its facet. After excluding these four items F302、F602、F903 and F901 (only 1 item left in the facet),the CFA was recomputed on the remaining items. The result showed better goodness of fit index:NNFI =0.955,RMSEA =0.0641,CFI =0.961,the parameters estimated were reasonable and statistically significant(t>2). The result of psychological domain showed better goodness of fit index: NNFI =0.968,RMSEA =0.0832,CFI =0.978;The factor loading of items ranged from 0.490 to 0.834, and were statistically significance(t>2);The determinant coefficients in testing formula were between 0.314(F1201) and 0.860(F1202).The result of social accommodation showed better goodness of fit index after modifying the model: NNFI =0.966,RMSEA =0.0682,CFI =0.973 ; The parameters estimated were reasonable and statistically significant(t>2). The results of all items in CSHS showed that 4 items F1402, F18, F2002 and F2001 were recommended to be deleted because of negative covariance (F1402, F18, F2002) and only one item left (F2001). The result of CFA on the remaining items showed better goodness of fit index: NNFI =0.915,RMSEA =0.0866,CFI =0.915; The parameters estimated were reasonable and statistically significant(t > 2). The CFA was conducted at domain level to test the goodness of fit index of 3 latent variable (physical, psychological, social accommodation) model and 4 talent variable (physical, psychological, social accommodation, sex behavior) model. The result supported 3 latent variable model and suggested sex behavior domain to be a new facet of social accommodation domain.
Finally, the refined CSHS-4 includes 3 domains (physical, psychological, social accommodation), 13 facets.
第一个阶段研究是提出中国人亚健康状态初始调查问卷(CSHS-1)。课题组首先研究确定亚健康的概念及范畴,并将其分解,初步确定中国人亚健康状态调查问卷的内容结构,包括四个领域(躯体表现、心理表现、社会适应性及生活方式),13个方面(疲劳、消化、睡眠、机能失调、免疫力、衰老、抑郁、焦虑、安全感、学习和记忆力、社会适应、生活方式、性生活)。在文献回顾的基础上,参考国际上公认的健康测量量表,提出中国人亚健康状态调查问卷的条目池。采用Delphi法进行条目初筛,保留重要的、敏感性高、独立性强、代表性好、具有可操作性和可接受性的条目。经过60位文化程度中等人士的预试和条目修订,形成了中国人亚健康状态初始调查问卷(CSHS-1),包括四个领域(躯体表现、心理表现、社会适应和生活方式)、13个方面(疲劳、消化、睡眠、机能失调、免疫力、衰老、抑郁、焦虑、安全感、学习和记忆、社会适应、生活方式、性生活),共74个条目。
第二个阶段的研究是进行预调查,筛选条目,形成中国人亚健康状态正式调查问卷(CSHS-2)。课题组采用第一阶段形成的初始调查问卷(CSHS-1)进行预调查,预调查在上海、南通、河北、河南、云南五个研究中心展开,采用整群随机抽样方法确定调查对象,共收回有效调查问卷544份。采用频数分析、离散趋势分析、相关分析、探索性因子分析、聚类分析和内部一致性分析筛选条目,结果保留46个条目。在此基础上,课题组对问卷内容进行调整,新增32个条目,形成中国人亚健康状态的正式调查问卷(CSHS-2),包括4个领域(躯体表现、心理表现、社会适应和性生活)、15个方面(疲劳、消化、睡眠、机能失调、免疫力、不适、疼痛、便秘、抑郁、焦虑、安全感、学习和记忆力、压力、满意感、性生活),共78个条目。
第三个阶段的研究是进行现场调查,进行量表条目筛选,形成中国人亚健康量表(CSHS-3)。课题组使用第二阶段形成的正式调查问卷(CSHS-2),采取整群随机抽样方法,对上海市两个体检中心的856名调查对象进行了现场调查,经过数据整理,确定462例合格样本数据(数据1)用于量表条目筛选。筛选量表条目采用的统计学方法包括:频数分布、条目分析、内部一致性分析和探索性因子分析。频数分析主要考核量表各条目得分的天花板和地板效应(ceiling effect & floor effect),删除天花板和地板效应较大的条目;条目分析主要考核量表中每个条目对的贡献大小,计算条目得分与量表总分,以及条目得分与所属方面得分的相关系数,删除相关系数过小,或与其他方面相关系数较大的条目;内部一致性分析采用Cronbachα系数考核量表总的、各领域和各方面的内部一致性。如果去除某一条目后,相应方面的Cronbachα系数有较大升高,则删除该条目;采用探索性因子分析,根据各条目在因子上的载荷大小筛选条目。如果条目在单个因子上的载荷小于0.35,或在两个或两个以上因子上的载荷均超过0.35,则删除该条目。经过上述分析,如果一个条目被两种或两种以上方法建议删除,则删除该条目。结果共删除23个条目,保留55个条目。
相关分析结果显示:反映抑郁和焦虑两个方面的条目有较强的关联关系,建议将两个方面合并成一个新的方面(抑郁焦虑),该结果与因子分析结果一致,即反映抑郁和焦虑的条目在同一个因子上载荷较大。研究结果确定中国人亚健康量表(CSHS-3)包括4个领域(躯体表现、心理表现、社会适应、性生活)、13个方面(疲劳、消化、睡眠、不适、疼痛、机能失调、免疫力、便秘、抑郁焦虑、记忆力、压力、满意感、性生活)、共55个条目。
第四个阶段研究是进行现场调查,考核量表的信度和效度,验证量表结构,进一步完善量表。课题组采用第三阶段形成的调查问卷(CSHS-3),采用整群随机抽样的方法,对全国9个地区的10000例调查对象进行现场调查。调查地区包括上海、西安、扬州、昆明、泸州、石家庄、郑州、河南、芜湖,要求各中心在确定调查对象时考虑被调查对象在性别、年龄和职业等方面的均衡。由于现场调查正在进行中,本文仅对已经收回的四个地区(上海、西安、河南、河北)的876例被调查对象的数据(数据2)进行分析。从内部一致性、重测信度和分半信度三个方面考核量表信度;从结构效度、标准关联效度和区分效度三个方面考核量表的效度;采用验证性因子分析考核量表结构是否与假设的理论模型一致。
内部一致性分析结果显示:量表总的Cronbachα系数为0.93;除性生活领域(仅有2个条目组成)外,其他三个领域的Cronbachα系数在0.83-0.93之间;除便秘、记忆力和性生活方面(仅有2个条目)外,其他10个方面的Cronbachα系数在0.67-0.84之间,结果表明量表有较好的内部一致性。重复测量分析结果显示:量表总的重测信度为0.91;4个领域的重测信度在0.76(性生活)到0.93(躯体表现)之间;13个方面的重测信度在0.63(疲劳)到0.87(便秘)之间,结果表明量表测量结果具有较好的稳定性和一致性。分半信度分析结果显示:量表总的分半信度为0.95;除性生活领域(仅有2个条目)外,其他3个领域的分半信度分别为0.92(躯体表现)、0.88(心理表现)和0.83(社会适应),结果表明量表有较好的分半信度。
结构效度分析结果显示:领域得分与总分之间的Spearman相关系数在0.32(性生活)-0.93(躯体表现)之间;方面得分与量表总分之间的Spearman相关系数在0.32(性生活)-0.77(抑郁焦虑)之间;除性生活领域(只包括1个方面)外,其他方面与所属领域间的Spearman相关系数均在0.56(便秘)-0.97(压力)之间,分析结果表明,性生活领域结构效度较低,其他领域和方面均有较好的结构效度。标准关联效度分析结果表明:量表各领域和方面与主观健康得分之间有较弱的标准关联效度。区分效度分析结果表明,55个条目均有很强的区分健康人、亚健康人和病人的能力,也具有很强的区分量表总分较高(上30%)和较低(下30%)人群的能力。
验证性因子分析分别从领域和整个量表的角度验证量表结构的优劣。躯体表现领域验证性因子分析结果表明:条目F602和F903未标准化负荷异常,F302在所属方面(潜变量)上的因子负荷小于0.35,建议删除这3个条目。删除条目F302、F602、F903和F901(因为便秘方面仅剩下1个条目)后,躯体表现领域验证性因子分析结果表明模型拟合良好:NNFI =0.955,RMSEA =0.0641,CFI =0.961,参数估计值比较合理且有统计学意义(t>2)。心理表现领域验证性因子分析结果表明模型拟合良好:NNFI =0.968,RMSEA =0.0832,CFI =0.978;各条目因子负荷在0.490-0.834之间,且有统计学意义(t>2);所有测量方程的决定系数在0.314(F1201)-0.860(F1202)之间。社会适应领域的验证性因子分析结果显示:经过模型修正,模型拟合良好:NNFI =0.966,RMSEA =0.0682,CFI =0.973;参数估计合理且有统计学意义。
整个量表结构的验证性因子分析结果显示:条目F1402、F18、F2002因协方差为负值,建议删除,F2001因该方面仅剩下一个条目,暂时不考虑;删除F1402、F18、F2002、F2001后,验证性因子分析结果显示模型拟合良好:NNFI =0.915,RMSEA =0.0866,CFI =0.915;参数估计合理,且有统计学意义。将各领域得分作为观测变量,比较亚健康的三因子(躯体表现、心理表现、社会适应)模型和四因子(躯体表现、心理表现、社会适应和性生活)模型的优劣,分析结果支持三因子结构模型,建议将反映性生活的方面归属到社会适应领域,作为社会适应领域的一个方面。
最后,获得修正后的中国人亚健康量表(CSHS-4),包括3个领域(躯体表现、心理表现和社会适应)、13个方面(疲劳、消化、睡眠、不适、疼痛、机能失调、免疫力、便秘、抑郁焦虑、记忆力、压力、满意感、性生活)、共47个条目。
The overall aim of the present study was to develop a sub-heath scale that is suitable for Chinese aged from 20 to 60 years old (the Chinese Sub-heath Scale, CSHS). This paper describes the development and validation of CSHS. After four phases of researches, we have proposed the CSHS-4, which includes 47 items, 13 facets (fatigue, digestion, sleep, indisposition, ache, dysfunction, immunity, constipation, depression and anxiety, memory, pressure, satisfaction, sex behavior) and 3 domains (physical, psychological and social accommodation) with the use of classical and contemporary statistical technique.
The analytic results of the present field data (data2) show that the CSHS-3 is a reliable measuring instrument with good reliability and validity. The confirmatory factor analysis of CSHS-3 suggests that the 3 domain (physical, psychological and social accommodation) solution is appropriate and sex domain is recommended to be a new facet of social accommodation domain.
The goal of the first phase study was to generate the initial SCHS questionnaire (CSHS-1). First of all, the research group worked to determine the concept and scope of sub-health and decompose it into four domains (physical, psychological, social accommodation and life style), 13 facets (fatigue, digestion, sleep, indisposition, immunity, aging, depression, anxiety, feeling of safety, learning and memory, social accommodation, life style, sex behavior). A draft item pool of SCHS questionnaire was developed based on the literature review and referring the wildly used measures for assessing health-related issues. These items were primarily screened by experts using Delphi technique and the items with more importance, high sensitivity, stronger independence, better representation, maneuverability and acceptability were reserved. After being pre-tested and modified by 60 middle-degree educated subjects, the initial questionnaire (CSHS-1) was determined, which covers 4 domains (physical, psychological, social accommodation and life style), 13 facets (fatigue, digestion, sleep, dysfunction, immunity, aging, depression, anxiety, feeling of safety, learning and memory, social accommodation, life style, sex behavior), and includes 74 items totally.
The aim of the second phase research was to conduct pretest, select items and then generate the formal questionnaire of CSHS (CSHS-2). A pre-test was carried out in 5 centers nationwide, they were located in Shanghai, Nantong Hubei, Hunan and Yunnan. The instrument applied was the CSHS-1 questionnaire proposed in phaseⅠ. The participants were determined by group randomized sampling method. 544 valid questionnaires were selected. Items were tested and reduced by 6 methods, frequency analysis, dispersion trend analysis correlation analysis, exploratory factor analysis, cluster analysis and internal consistency analysis. As a result 46 items were reserved. Based on this result, the questionnaire was adjusted and 32 additional items were added to form the formal CSHS questionnaire (CSHS-2), which includes 4 domains: (physical, psychological, social accommodation and sex behavior), 15 facets (fatigue, digestion, sleep, dysfunction, immunity, indisposition, ache, constipation, depression, anxiety, feeling of safety, learning and memory, pressure, satisfaction and sex behavior), and 78 items.
In the third phase research, a field research was conducted to collect data on the CSHS items for the purpose of item testing and reduction and proposing the CSHS-3. The CSHS-2 proposed in phaseⅡwas applied to 856 volunteers from 2 medical examination centers of Shanghai. 462 valid questionnaires were used as the dataset (data1) to test and reduce items after data processing. The statistical methods applied in item testing and item reduction were frequency analysis, item analysis, internal consistency analysis and exploratory factor analysis. Frequency analysis was used mainly for the purpose of checking ceiling and floor effect of item responds. The items with more than 20% ceiling or floor effect should be excluded. Item analysis was undertaken to examine the contributions of individual items within the scale. Item-total and item-facet score correlations were calculated, items of smaller coefficients and/or of larger correlation coefficients with other facets were excluded. Internal consistency of total, domains and facets was assessed using Cronbachαcoefficient. The item should be excluded if the corresponding facet’s Cronbachαcoefficient greatly increases after deleting the item. Exploratory factor analysis was used for the purpose of selecting items according to their loading on each factor. The item should be excluded if the item has a factor loading of less than 0.35 or greater than 0.35 on two or two more factors. Through the analysis of the four methods mentioned above, the items should be excluded if they were recommended to be deleted by the results of two or more methods. Thus, 55 items are reserved while 23 items are deleted. The result of correlation analysis shows that the items of depression and anxiety facet are recommended to be merged as a new facet called depression and anxiety facet due to high correlation, as recommended by the result of exploratory factor analysis, the items of depression and anxiety facet have high loading on the same factor. Finally, the refined CSHS questionnaire (CSHS-3) is composed of 4 domains 4 domains(physical, psychological, social accommodation, sex behavior), 13 facets(fatigue, digestion, sleep, indisposition, ache, dysfunction, immunity, constipation, depression and anxiety, feeling of safety, memory, pressure, satisfaction, sex) and 55 items.
A large scale field research was conducted in phaseⅣfor the purpose of assessing validity and reliability of CSHS-3 proposed in phaseⅢ. The participants were determined by group randomized sampling method. 9 centers nationwide involved in the research, they were located in Shanghai, Xian, Yangzhou, Kunming, Luzhou, Shijiazhuang, Zhengzhou, Henan and Wuhu. The CSHS questionnaire proposed in phaseⅢwas applied to 10000 participants.
The centers were requested to consider the balance of gender, age and occupation of volunteers when they were recruited. The presented 876 questionnaires were only from 4 sites (Shanghai, Xian, Henan and Hebei) because the field research is on going now. Internal consistency, test-retest reliability and split-half reliability were used to check the reliability of CSHS-3. Construct validity, criteria-related validity and discriminant validity were used to examine the validity of CSHS-3. Confirmatory factor analysis was conducted with LISREL8.53 to test if the scale construction was consistent to that of hypothesized model.
The result of internal consistency analysis showed a better internal consistency of CSHS-3. The Cronbachαcoefficient for total score was 0.93. Except sex behavior domain (includes two items); Cronbachαcoefficient for other three domain score ranged from 0.83 to 0.93 and Cronbachαcoefficient for 10 facet score (except constipation, memory and sex behavior facet that includes two items) ranged from 0.67 to 0.84. The result of test-retest analysis shows good test-retest reliability. Correlation coefficient for the total score was 0.91, for 4 domains ranged from 0.76 (sex behavior) to 0.93 (physical), for 13 facets ranged from 0.63 (fragile) to 0.87 (constipation). The result of split-half reliability analysis indicates a high correlation between halves. The split-half correlation coefficient for CSHS-3 was 0.95, for physical domain (0.92), psychological domain (0.88) and for social accommodation domain (0.83). The result of construct validity analysis showed that most domains and facets had better construct validity except sex behavior domain. The Spearman correlation between domain score and total score ranged from 0.32 (sex behavior) to 0.73 (physical domain). The Spearman correlation between facet scores and total score ranged from 0.32 (sex behavior) to 0.77 (depression and anxiety). Except that the sex behavior domain had single facet, The Spearman correlation between facet score and domain score ranged from 0.56 (constipation) to 0.97 (Pressure). The result of criteria-related validity analysis showed a weak criteria-related validity. The Spearman correlation between domain/facet score and subjective health score ranged between 0.10 (sex behavior) to 0.27 (physical domain). The result of Discriminant validity analysis showed that the 55 items had strong Discriminant validity. Each of the 55 items had statistically significant difference among healthy, sub-healthy and patient groups, and also between the upper 30% and the lower 30% total score groups. Three domains and the whole CSHS-3 were tested using confirmatory factor analysis (CFA). The result of physical domain showed that three items F602, F903 and F302 were suggested to be excluded because of abnormal parameters and lower factor loading on its facet. After excluding these four items F302、F602、F903 and F901 (only 1 item left in the facet),the CFA was recomputed on the remaining items. The result showed better goodness of fit index:NNFI =0.955,RMSEA =0.0641,CFI =0.961,the parameters estimated were reasonable and statistically significant(t>2). The result of psychological domain showed better goodness of fit index: NNFI =0.968,RMSEA =0.0832,CFI =0.978;The factor loading of items ranged from 0.490 to 0.834, and were statistically significance(t>2);The determinant coefficients in testing formula were between 0.314(F1201) and 0.860(F1202).The result of social accommodation showed better goodness of fit index after modifying the model: NNFI =0.966,RMSEA =0.0682,CFI =0.973 ; The parameters estimated were reasonable and statistically significant(t>2). The results of all items in CSHS showed that 4 items F1402, F18, F2002 and F2001 were recommended to be deleted because of negative covariance (F1402, F18, F2002) and only one item left (F2001). The result of CFA on the remaining items showed better goodness of fit index: NNFI =0.915,RMSEA =0.0866,CFI =0.915; The parameters estimated were reasonable and statistically significant(t > 2). The CFA was conducted at domain level to test the goodness of fit index of 3 latent variable (physical, psychological, social accommodation) model and 4 talent variable (physical, psychological, social accommodation, sex behavior) model. The result supported 3 latent variable model and suggested sex behavior domain to be a new facet of social accommodation domain.
Finally, the refined CSHS-4 includes 3 domains (physical, psychological, social accommodation), 13 facets.
引文
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