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Chi & Boey (1993 Hong Kong Validation of Measuring Instruments of Mental Health Status of The Elderly)

The article discusses the validation of mental health measurement instruments for the elderly in Hong Kong, addressing the growing aging population and the lack of empirical data on their mental health status. It evaluates the reliability and validity of four psychogeriatric instruments: GHQ-30, SPMSQ, CESD, and LSI-A, through a study involving normal and clinical elderly groups. The findings indicate that these instruments are reliable and have good discriminative power for assessing mental health in the elderly population.

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0% found this document useful (0 votes)
17 views19 pages

Chi & Boey (1993 Hong Kong Validation of Measuring Instruments of Mental Health Status of The Elderly)

The article discusses the validation of mental health measurement instruments for the elderly in Hong Kong, addressing the growing aging population and the lack of empirical data on their mental health status. It evaluates the reliability and validity of four psychogeriatric instruments: GHQ-30, SPMSQ, CESD, and LSI-A, through a study involving normal and clinical elderly groups. The findings indicate that these instruments are reliable and have good discriminative power for assessing mental health in the elderly population.

Uploaded by

deeg42511
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd

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Clinical Gerontologist
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Hong Kong Validation of Measuring


Instruments of Mental Health Status of
the Elderly
a b
Iris Chi DSW & K. W. Boey PhD
a
Professor and Director, Department of Social Work & Social
Administration, University of Hong Kong, Hong Kong
b
Department of Social Work & Social Administration, University
of Hong Kong, Hong Kong
Published online: 25 Oct 2008.

To cite this article: Iris Chi DSW & K. W. Boey PhD (1993) Hong Kong Validation of Measuring
Instruments of Mental Health Status of the Elderly, Clinical Gerontologist, 13:4, 35-51, DOI:
10.1300/J018v13n04_04

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Downloaded by [University of Auckland Library] at 16:14 09 February 2015
Hong Kong Validation
of Measuring Instruments
of Mental Health Status of the Elderly
Iris Chi, DSW
K.W. Boey, PhD
Downloaded by [University of Auckland Library] at 16:14 09 February 2015

INTRODUCTION
As experienced by many industrialized societies in the world, Hong
Kong is having to face the challenge of a very fast growing, aging popula-
tion. It has been estimated that, by the year 2001, there will be approxi-
mately 909,500 elderly people in Hong Kong (Census & Statistics Depart-
ment, 1984) and that more than 14% of the total population will be aged 60
or over. The incidence and seriousness of mental disorders is affected by
age. The mental health needs of the elderly are particularly amenable to
population-focused interventions. As Olsen (1979) pointed out, in terms of
numbers and personal and social costs, the most urgent problem confront-
ing social and health policy planners, in the future, is the care and provi-
sion of services for the elderly, particularly, the elderly mentally infirm.
In most of the industrialized societies, it is estimated that about 10
percent of the older population have mental disorders which cause some
degree of disability. The Research Department of the Hong Kong Council
of Social Services has listed more than 60 studies conducted locally on
various topics concerning the elderly since the 1970s (Hong Kong Council
of Social Service, 1986). However, factors such as mental health, psycho-
logical well being, cognitive functioning, and quality of life have never
been systematically studied. There is basically no empirical data on the
mental health status of the elderly people in Hong Kong. The closest study
on this topic was a random sample health survey, conducted in 1988,

Iris Chi and K.W. Boey are affiliated with the Department of Social Work &
Social Administration, University of Hong Kong, Hong Kong.
Clinical Gerontologist, Vol. 13(4) 1993
O 1993 by The Haworth Press, Inc. All rights reserved. 35
36 CLINICAL GERONTOLOGIST

which showed that many of the Hong Kong elderly people were depressed
and bored (Chi and Lee, 1989).
One of the reasons, given by local researchers and practitioners for the
lack of research in this area is that there are no valid and reliable instru-
ments which can be used. In view of this, the objective of this study is to
establish the validity and reliability of several internationally well-known
psychogeriatric measurements in their applications to local elderly sub-
jects. These measurements include: (1) General Health Questionnaire-30
items version (GHQ-30); (2) Short Portable Mental Status Questionnaire
(SPMSQ); (3) Centre for Epidemiological Studies Depression Scale
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(CESD); and (4) Life Satisfaction Index-A Form (LSI-A). A resume of


these measures is outlined as follows:
1. General Health Questionnaire-30 items version (GHQ-30). The
General Health Questionnaire (GHQ) is a self-administered screen-
ing test aimed at detecting minor psychiatric disorders among re-
spondents in community settings (Goldberg, 1978). It is a type of
symptom checklist to compare respondent's recent experience to
their usual state. The original version of GHQ consists of 60 items
and employs a 4-point scale ranging from "less usual than usual" to
"much more than usual." In the present study, 30 items version of
the GHQ is used. There is evidence that the GHQ-30 has good valid-
ity and reliability among different subjects in different cultural con-
texts. However, its applicability to the elderly remains to be estab-
lished.
2. Short Portable Mental Status Questionnaire (SPMSQ).The SPMSQ
developed by Pfeiffer (1975) is a measure of cognitive functioning
of the elderly. It consists of only ten items which can be easily ad-
ministered by trained interviewers. Items included in SPMSQ are
thorough, in terms of the realm of cognitive functioning which they
covered. It has been widely used not only because of its convenience
but also because of its high validity and reliability (Kane & Kane,
1981). In the present study, some items in SPMSQ were modified in
order to fit into the local context. A correct answer in the SPMSQ
scores one point while wrong or missing answers score zero. The
range of total scores was from 0 to 11.
3. Centrefor Epidemiological Studies Depression Scale (CESD). It is a
20-item scale designed to measure the current level of depressive
symptomatology of individuals in the general population. Respon-
dents were asked to indicate how frequently they experienced each
symptom in the previous week on a 4-point Likert type scale. The
items included were depressed mood, feelings of guilt and worth-
iris Chi and K. W Boey 37

lessness, feelings of hopelessness, psychomotor retardation, appetite


loss, and sleep disturbance. CESD is a useful screening device to
identify persons who may be at risk of depression (Radloff, 1977).
4. Life Satisfaction Index-A Form (LSI-A). The scale used in our study
was a modified version of LSI originally developed by Neugarten
and associates (1961) in order to measure life satisfaction in a way
which is "relatively independent of level of activity or social partici-
pation" (Adams, 1969). LSI-A consists of 18 statements related to 5
different components: zest, resolution and fortitude, congruence be-
tween desired and achieved goals, positive self-concept, and mood
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tone. Respondents were asked to indicate whether they agree or dis-


agree on these statements. Response indicating life satisfaction was
scored with 1 point. The range of total scores was from 0 to 18.

This study adopted a two group comparison method. It was conducted


in three stages. In the first stage, internal consistency of the instruments
was evaluated by means of Cronbach's Alpha and split-half reliability. In
the second stage, the design was geared to assess the discriminative power
of the instruments by comparing clinical and normal elderly groups. In the
final stage of the study, test-retest reliabilities of the instruments were
assessed.
Since most of the elderly people in Hong Kong are less educated (De-
partment of Social Work, 1982; Chi & Lee, 1989), a face-to-face struc-
tured interview schedule with close-ended questions which were phrased
in simple statement was employed for data collection. The four measuring
instruments were first translated from English to Chinese and then trans-
lated back to English by a translator to ensure the quality of the translation.
Issues with ambiguous meaning or inappropriate to the local context were
dropped. The questionnaire had been counter-checked by two clinical
psychologists and a geropsychiatrist. A pilot study was conducted by
interviewing 6 elderly members of the St. James' Settlement before it was
finalized.

Subjects

Subjects in this study (N = 91) were either normal elderly of the Adult
Service Division or patients of the Psychogeriamc Assessment Clinic in
the St. James' Settlement. St. James' Settlement is one of the largest
38 CWNICAL GERONTOLOGIST

voluntary social service agencies in Hong Kong. The Division, in collabo-


ration with the Psychiatric Unit of the University of Hong Kong, set up a
Psychogeriatric Assessment Clinic in October, 1984.
In Stage I of the study, normal elderly were selected by means of
stratified systematic sampling method. Approximately, equal proportions
of males and females in 3 age groups (60 to 70, 70 to 80, and 80 and
above) were selected from a list of registered members in the Adult Ser-
vice Division. A total of 31 elderly were interviewed at this stage. To
assess test-retest reliability, this group of respondents were interviewed
again after an interval of 5 to 7 weeks.
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In Stage II, another group of normal elderly (N = 30) which matched


closely with the clinical group was also-selected from the elderly member-
ship list using systematic sampling method. The clinical group was re-
ferred by psychiatrists of the Psychogeriatric Assessment C l i c . They
assessed the respondents in Ulis group to select who was suitable for
interviews. Participants either lived in institutions, e.g., homes for the
elderly or in the community and they came from all districts of Hong
Kong. Only patients with depression, paranoid disorder and dementia
were included in the present study. Patients with severe dementia prob-
lems and those who could not complete a significant portion of the ques-
tionnaire were dropped from the list of the sampling frame and replace-
ments were sought accordingly. There were 31 cases in this clinical group,
including 10 depressive cases, 15 senile dementia, 1 with Alzheimer dis-
ease, and 5 with paranoid disorder.
Table 1 shows the characteristics of the elderly respondents. In the first
normal group (stage I), slightly more females were interviewed than males.
The majority (45.2%) of respondents were aged between 60 and 69. Only
16% of them were the old-old, aged 80 or over. Approximately, half of the
respondents were married and one third were widowed More than half of
the respondents had no formal schooling. Only one elderly respondent was
still working. The fmancial status of the elderly, in terms of whether or not
they had enough money to cover daily expenses was also assessed. Over
half (54.8%) of our sample reported that they had enough or more than
enough money to cover their daily expenses. A slightly less proportion of
respondents claimed that they had just enough money to make ends meet.
Only one respondent reported insufficiency.
The health condition of the respondents was assessed by (a) self-rated
health and (b) whether they were hospitalized in the previous year or not.
Only 25.9% of respondents regarded their present health status as good or
very good, while about one third of them reported poor or very poor
health. Over one Fifth (22.6%) of the respondents were hospitalized in the
Iris Chi and K.W.Boey

Demogmphlc Varinbles of the Normal Croups & Clinical Croup


- - ~~.

Group

Sex:
Male
Female
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Age:
60-69
70-79
80+

' MaritJ Status:


Married
Widowed
Others

Years 01Formal Education:

Work Status:
Rclired
Never Work/Housewife
Working

Financial Status:
Suficient/V. Suficicnt
Just make ends meet
Insufficienl

Self-assessed Health:
Poor/Vcry Poor
Fair
Good/Very Good

Hospitalized in Previous Year

a N-31

b N = M

p < .05 Chi-square comparison between 2nd Normal and Clinical Group
40 CLINICAL GERONTOLOGIST

previous year. The second normal group and the clinical group were well
matched except for sex and hospitalization. There were more females and
a higher rate of hospitalization in the clinical group.

RESULTS

Reliability of the Instruments

Internal consistencies were examined in terms of Cronbach's Alpha,


Downloaded by [University of Auckland Library] at 16:14 09 February 2015

split-half and test-retest reliability. As shown in Table 2, all the instru-


ments had satisfactory reliability. As SPMSQ consists of items which are
not homogeneous, its reliability was assessed in terms of temporal stabil-
ity. In the case of CESD and LSI-A, a test-retest reliability was not con-
ducted for practical reasons. For instance, items of CESD and LSI-A are
too depressing. These two scales were administered only once for the
elderly.

Validity of Instruments

To establish the validity of the instruments, scores obtained by the


normal group and the clinical group in Stage I1 are compared. Differences
between these two groups on ADL, GHQ-30, CESD,LSI-A, SPMSQ, and
LSNS were statistically sigmficant, indicating that the five measuring
instruments have very good discriminating power (Table 3).

Table 2

Reliability or Measurements a
... -- - --- - -

Cronbach's Alpha Split Half Test-Retest

CESD

LSI-A

GHQ
SPMSQ
Iris Chi and K. W.Boey

Tnble 3

Comparison of Menn Scores between


second Normal Group & Clioicnl Group
-- - . -
Groups

Normal Clinical t

SPMSQ 7.1 2.6 6.7"


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CESD 28.1 38.0 3.6"

UI-A U.7 8.6 23'

GHQ . 18.3 21.2 -2.8"

UNS 203 115 3.9"

Total ADL D i c u l t i e s 1.8 6.5 4.9-

In addition, clinical assessments from the psychiatrists matched well


with the scores indicated by GHQ-30, SPMSQ and CESD. Depressive
patients scored signhcantly higher than the others on both CESD and
GHQ-30 scales whereas the demented patients obtained the lowest scores
on the SPMSQ.
Adjustment of S P M S Q Score

Pfeiffer (1980) recommended that SPMSQ total score should be ad-


justed by education and ethnicity. In this study, the SPMSQ score was
significantly correlated with the years of formal education in the fist and
second normal groups (Table 4). This is consistent with past research
Fidings. However, no signif~cantcorrelation was found between educa-
tion and SPMSQ in the clinical group. This negative fmding could be
accounted for by the lower level of cognitive ability as well as the limited
score distribution among the clinical respondents.
In order to minimize the influences of education on the SPMSQ score,
the score of the normal group was adjusted by increasing 1 point for those
CWNICAL GERONTOLOGIST

Table 4

- -
Correlulion between SPMSQ Score nod Year of Education
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kt N o m d Group

SPMSQ

Adjusted SPMSQ

2nd Normal Group

SPMSQ

Adjusted SPMSQ

Clinical Group

SPMSQ

Adjusted SPMSQ

subjects who had no formal education background. This adjustment is


made on the basis that the majority of people (over 50%)in both the study
sample and the general elderly population, had no formal education After
the adjustment, no significant correlations between these two variables
were found, and the validity test of this adjusted score was still signf~cant.
Based on this result, the researchers felt that subjects may be classified
according to the adjusted score.
Iris Chi and K. W Boey 43

Although Pfeiffer outlined a four-group classification, he used two


groups in his initial validation study: (a) intact/mildly impaired, and
(b) moderatelylseverely impaired. Other researchers and clinicians recom-
mended three-group model: (a) minimally impaired, (b) moderately im-
paired, and (c) severely impaired (Smyer et al., 1979). Classifications for
the SPMSQ have been varied by different studies (Weiler, 1991). Four
levels of cognitive functioning (Table 5) were proposed, namely: cogni-
tively intact, those who scored 10 or more marks in the test; mildly im-
paired, those who scored between 8 to 9; moderately impaired, respon-
dents who scored between 5 to 7; and severely impaired, those who scored
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lower than 5.

Table 5

Percentnge Distributions of the Adjusted SPMSQ Score

Group

Score 1st Normal 2nd Normal Clinical

% % %

10-12 Intact 39.9 3.4 0.0

8-9 Mild 33.3 36.7 9.7

S-7 Moderate 25.6 26.6 25.8


44 CLJNICAL GERONTOLOGIST

CONCLUSZON

A less representative group of elderly people was selected because it was


limited by lack of resources. Caution should therefore be taken when inter-
preting and generalizing the findings of the survey. Nevertheless, this study
has focused on the specific areas most important for the assessment of
mental health and mental status of elderly people in Hong Kong. The major
measuring instruments examined in this study not only proved to have
satisfactory reliability but also possessed very good discriminatory validity.
Taking into consideration the effect of educational background, this
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study proposes an adjustment of the SPMSQ which sets a cutting point for
clinical practice. This type of information will be found useful for both
comparative research and clinical assessment purposes in the future.

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Chi, I. and Lee. J.J. (1989). A Health Survey of Elderly People in Hong Kong.
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Department of Social Work. (1982). A Study of Weyare Needs of the Elderly in
Hong Kong: The Nee& of the Elderly Living in the Community. Hong Kong:
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Goldberg, D. (1978). Manual of the General Health Questionnaire.Great Britain:
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Iris Chi and K. W Boey 45

Pfeiffer, E. (1980). The Psychosocial Evaluation of the Elderly Patients. In: Busse
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