The study aims to adapt and validate the Constitution in Chinese Medicine Questionnaire (CCMQ) in Hong Kong Chinese people. 10 patients and 10 Chinese medicine practitioners (CMP) confirmed the content validity (CVI: 50%–100%) of CCMQ. 1084 HK subjects completed a cross-sectional study with 98.6% who could be classified into one or more BC types. Scaling success rates were 85.7%–100% for the 9 BC scales. Construct validity was supported by moderate correlations between CCMQ and SF-12v2 scores. The confirmatory factor analysis showed a reproducible structure as hypothesized. People with gentleness BC type had better health-related quality of life, HRQOL, than those with other (imbalanced) BC types. Internal consistency (reliability) (Cronbach’s alpha > 0.6) and test-retest reliability were also satisfactory (ICC > 0.6) for all scales. However, the sensitivity and specificity in predicting the BC types diagnosed by CMP were only fair, ranging from 42.7% to 82.7%. 27.6% of subjects had a change from the imbalanced BC types to gentleness BC type after 6 months. The CCMQ was adapted for HK Chinese people and proved to be valid, reliable, and responsive. People classified to have imbalanced BC types had significantly lower HRQOL than gentleness BC type, which supported the validity and importance of the TCM concept of the physiological BC type.
Body constitution (BC), an ancient core concept in traditional Chinese medicine (TCM), is widely applied in daily practice by Chinese medicine practitioners (CMP), but there is little standardization on its measurement. Many debate and challenge on this which long regarded as subjective. Studies have found low agreement on the BC type diagnoses among CMP [
The Constitution in Chinese Medicine Questionnaire (CCMQ) was developed by Wang et al. in Mainland China [
The aim of this study was to adapt and validate the CCMQ in Hong Kong Chinese in order to establish evidence on its content and construct validity, reliability, sensitivity, and responsiveness.
To adapt the CCMQ to a HK version that is linguistically valid for Cantonese speaking Chinese in Hong Kong. To evaluate the content validity of the HK version of the CCMQ by Chinese medicine practitioners (CMPs) experts and lay persons in Hong Kong. To test the psychometric properties including construct validity by scaling assumptions, factor structure and known group comparison, criterion validity, reliability, sensitivity, and responsiveness of the HK version of CCMQ.
To evaluate the content validity of CCMQ, convenient samples of 10 patients and 10 Chinese medicine practitioners (CMP), respectively, were recruited from June to July, 2010, to complete the CCMQ and cognitive debriefings. A convenient age-gender stratified sample of Cantonese speaking patients was recruited from the Ap Lei Chau General outpatient clinic (ALCGOPC), and all subjects completed a written consent form. All CMP were academically qualified with a bachelor’s degree in CM and more than 5 years of clinical experience (average 7.2–8.4 years). The characteristics of the subjects are shown in Table
Patients’ baseline characteristics.
Cognitive debriefing patients | Patients |
Hong Kong general population (2010)a | |||
---|---|---|---|---|---|
|
|
( |
|||
Age (Year, mean |
|
|
NA | ||
Age group ( |
|||||
18–44 years | 5 (50%) | 376 (34.7%) | 2,875,380 (48.3%) | ||
45–64 years | 3 (30%) | 562 (51.9%) | 2,162,400 (36.3%) | ||
>65 years | 2 (20%) | 140 (12.9%) | 912,100 (15.3%) | ||
Refused to answer | 0 | 5 (0.5%) | NA | ||
Sex ( |
|||||
Male | 5 (50%) | 324 (29.9%) | 3,307,730 (46.8%) | ||
Female | 5 (50%) | 756 (69.8%) | 3,760,070 (53.2%) | ||
Marital status ( |
|||||
Married living with spouse | NA | 683 (63.1%) | 3,392,300 (57.6%) | ||
Single | NA | 282 (26.0%) | 1,894,100 (32.2%) | ||
Widower and separated/divorced | NA | 115 (10.6%) | 601,900 (10.2%) | ||
Refused to answer | NA | 3 (0.3%) | NA | ||
Education ( |
|||||
Nil | NA | 45 (4.2%) | 321,294 (5.4%) | ||
Primary | NA | 170 (15.7%) | 1,005,530 (16.9%) | ||
Secondary | NA | 488 (45.1%) | 3,105,837 (52.2%) | ||
Tertiary | NA | 139 (12.8%) | 434,341 (7.3%) | ||
Refused to answer | NA | 241 (22.3%) | NA | ||
| |||||
( |
|||||
Mean | SD | Floor% | Ceiling% | ||
| |||||
CCMQ scores | |||||
Gentleness | NA | 61.37 | 16.74 | 0 | 0.46 |
Qi-deficiency | NA | 33.62 | 17.52 | 1.30 | 0.09 |
Yang-deficiency | NA | 27.01 | 21.48 | 11.79 | 0.19 |
Yin-deficiency | NA | 26.67 | 16.64 | 5.10 | 0 |
Phlegm-wetness | NA | 26.81 | 17.42 | 4.82 | 0 |
Wetness-heat | NA | 26.36 | 17.01 | 7.88 | 0 |
Blood-stasis | NA | 27.74 | 16.24 | 3.25 | 0 |
Qi-depression | NA | 26.86 | 18.85 | 9.94 | 0 |
Special diathesis | NA | 24.50 | 17.09 | 4.91 | 0 |
SF-12v2 (HK norm) | |||||
PF (87.6) | NA | 83.24 | 25.24 | 2.43 | 61.72 |
RP (80.0) | NA | 75.59 | 26.83 | 2.23 | 38.88 |
BP (78.1) | NA | 69.12 | 29.31 | 4.65 | 35.97 |
GH (48.3) | NA | 34.63 | 20.95 | 11.01 | 0.84 |
VT (62.6) | NA | 55.29 | 26.45 | 6.77 | 9.46 |
SF (82.0) | NA | 81.97 | 24.38 | 2.41 | 55.24 |
RE (77.4) | NA | 77.18 | 24.46 | 1.30 | 38.38 |
MH (69.1) | NA | 68.71 | 20.37 | 0.84 | 11.84 |
PCS | NA | 46.19 | 9.94 | 0 | 0 |
MCS | NA | 50.34 | 10.58 | 0 | 0 |
PF: physical functioning; RP: role limitation due to physical problems; BP: bodily pain; GH: general health; VT: vitality; SF: social functioning; RE: role limitation due to emotional problems; MH: mental health; PCS: physical component score; MCS: mental component score; NA: not applicable.
2128 eligible patients attending a Western medicine (WM) outpatient clinic (ALCGOPC) and two Chinese medicine outpatient clinics were invited and 1084 patients participated in the cross-sectional validation study from July to October, 2010. The characteristics of the subjects are summarized in Table
The CCMQ was reviewed and adapted to be linguistically appropriate for Chinese people in Hong Kong by a professional translator to form a draft HK version of the CCMQ. This was sent to 10 Chinese medicine practitioners (CMPs) with the completion of the cognitive debriefing questionnaire (see Supplementary Appendix
To investigate the construct validity, reliability, sensitivity, and responsiveness of the CCMQ, each of the 1068 patients ≥18 years old answered the Hong Kong version of the CCMQ, the HK Chinese Short Form-12 version 2 Health Survey (SF-12v2) and a structured questionnaire on sociodemographics and chronic morbidity (Supplementary Appendix
To evaluate test-retest reliability, 225 patients attending the ALCGOPC for routine chronic disease followup were retested with the CCMQ (HK version) administered by telephone 2 weeks after the first test.
1084 subjects agreed to a follow-up survey in 3 to 6 months, and 404 subjects completed the telephone interviews with the HK versions of the CCMQ and SF-12v2 in addition to a one-item Global Rating Scale (GRS) on change in health condition [
Patient recruitment.
The sample size for cognitive debriefing study on content validity was recommended by an international group [
The Constitution in Chinese Medicine Questionnaire (CCMQ) [
The Chinese (HK) Short Form-12 version 2 (SF-12v2) Health Survey is a health-related quality of life (HRQOL) measure that has been translated, validated, and normed on the general Chinese population in Hong Kong [
The Global Rating on Change Scale (GRS) asked the subjects to rate on the change in his/her own illness condition since the initial TCM/WM consultations. The response was given as a score of zero for no change, +1, 2, or 3 for different degrees of improvement, and −1, 2, or 3 for different degrees of deterioration.
The content validity indexes (CVI), the proportion of subjects who gave a positive rating, on clarity and relevance, was calculated for each item [
The scaling assumptions were tested by (i) item-scale correlations, against the hypothesis that there should be substantial linear correlations
CFA was used to determine whether the items load onto the hypothesized subscales by the Satorra-Bentler scaled chi-square statistic [
Correlations between scores of corresponding subscales of CCMQ were calculated by Spearman’s correlation. Known-group comparison would be considered by studying the difference of CCMQ and SF-12 scores by gender and age groups in Mann-Whitney
CMP diagnosis of the BC type was used as the “gold standard”. The sensitivity and specificity of the CCMQ in predicting the CMP BC type diagnosis were calculated. The agreement between the diagnoses by the CCMQ with the CMP was assessed by the Kappa coefficient of which “1” indicates complete agreement and “0” complete disagreement [
The sensitivity of the CCMQ (HK version) was tested by patients with different levels of demographic groups (i.e., age and genders). It was hypothesized that patients who were older or female would have higher CCMQ scores [
Internal consistency of CCMQ was measured by Cronbach’s alpha that indicates the extent to which items in a scale are homogeneous in supporting the same concept. Test-rest reliabilities of CCMQ scales were evaluated by intraclass correlations (ICC) and paired
The proportion of subjects who had a change in the BC type classified by the CCMQ in 3–6 months was used as a measure of the responsiveness of the instruments to detect a change over time from summer to winter seasons. According to the Chinese medicine theory, 10–20% of patients would expect to have a change in their BC types. Subjects were divided into the gentleness BC type or any imbalanced BC types at the baseline survey, and the proportion of each with a change in the gentleness or imbalanced BC types classification was determined. The change in the mean scale scores of subjects who have reported a change in the health condition measured by the GRS was analyzed and this would be tested by paired
Confirmatory factor analysis was adopted in LISREL 8.80, and other data analysis was carried out in SPSS for window 17.0. Statistical significant levels were set at
Time taken to complete the CCMQ by patients was 10.9 ± 5.4 minutes, while it was 15.6 ± 8.9 for Chinese medicine practitioners (CMPs). The CCMQ had satisfactory CVIs (≥80%) on clarity, consistency of response options, and relevance with health in all items except for 6 items (Table
The CVIs of CCMQ rated by Chinese medicine practitioners (CMPs) and lay persons.
CMP |
Lay persons |
|
---|---|---|
Scale (Items) rated to be clear | ||
Response options “often” ( |
|
100 |
Gentleness (total 8 items) | 70–100 | 50–100 |
“53. Are you capable to adapt to the external changes of the natural and social environment?” | 70 |
|
Qi-deficiency (total 8 items) | 60–100 | 60–100 |
“3. Will you easily feeling shortness of breath (gasping for breath)?” |
|
100 |
“4. Will you easily feeling palpitation?” | 90 |
|
Yang-deficiency (total 7 items) | 80–100 | 100 |
Ying-deficiency (total 8 items) | 80–100 | 90–100 |
Phlegm-wetness (total 8 items) | 80–100 | 70–100 |
Wetness-heat (total 6 items) | 90–100 | 60–100 |
“60. Have you feeling wetness in your scrotum (for men only)?” | 100 |
|
Blood stasis (total 7 items) | 80–100 | 90–100 |
Qi-depression (total 7 items) | 60–100 | 90–100 |
“10. Do you think you are sentimental or fragile emotionally?” |
|
100 |
Special diathesis (total items: 7) | 80–100 | 80–100 |
Scales rated to be consistent with response options | ||
Gentleness (total 8 items) | 80–100 | 80–90 |
Qi-deficiency (total 8 items) | 80–100 | 80–90 |
Yang-deficiency (total 7 items) | 90–100 | 90 |
Ying-deficiency (total 8 items) | 90–100 | 90 |
Phlegm-wetness (total 8 items) | 90–100 | 80–90 |
Wetness-heat (total 6 items) | 100 | 80–100 |
Blood stasis (total 7 items) | 90–100 | 70–90 |
Qi-depression (total 7 items) | 90–100 | 90 |
Special diathesis (total 7 items) | 80–100 | 80–90 |
Scales rated to be relevant to health | ||
Gentleness (total 8 items) | 70–100 | 40–100 |
“53. Are you capable to adapt to the external changes of the natural and social environment?” | 70 |
|
Qi-deficiency (total 8 items) | 80–100 | 50–100 |
“6. Do you like quiet and bothered to talk?” | 80 |
|
Yang-deficiency (total 7 items) | 80–100 | 90–100 |
Ying-deficiency (total 8 items) | 70–100 | 70–100 |
Phlegm-wetness (total 8 items) | 80–100 | 70–100 |
Wetness-heat (total 6 items) | 80–100 | 70–100 |
Blood stasis (total 7 items) | 80–100 | 70–100 |
Qi-depression (total 7 items) | 80–100 | 50–100 |
“14. Will you sign without any intention?” | 80 |
|
Special diathesis (total 7 items) | 80–100 | 70–100 |
On the other hand, the interpretation of 5 items including the response options “often” (
The CCMQ draft version and the final CCMQ (HK) version
Draft Hong Kong version | Final Hong Kong version |
| |
Items | |
| |
“3. Will you easily feeling shortness of breath (gasping for breath)?” |
“3. Will you easily feeling shortness of breath |
| |
“26. Will you easily sweat excessively with only a slight movement?” |
“26. Will you sweat excessively with only a slight movement (it seems you sweat more than others)?” |
| |
“31. Will you easily having skin urticaria (wheal or wind knots)?” |
“31. Will your skin easily having rubella (including wind groups, gives or wind knots)” |
| |
“32. Will you easily getting skin allergic purpura |
“32. Will you easily getting allergies of purple erythema (purple blood spots or petechiae)?” |
| |
Response option | |
| |
“Always” |
“For most of the time” |
The baseline score distribution, floor and ceiling effect proportions of the CCMQ, and SF-12v2 scales are shown in Table
The distribution of body constitution classified by CCMQ.
Frequency ( |
|||
---|---|---|---|
Baseline |
2 weeks |
3–6 months |
|
Body constitution classification by CCMQ* | |||
(1) Gentleness | 215 (20.0%) | 112 (50.5%) | 143 (36.7%) |
(2) Qi-deficiency | 607 (56.2%) | 63 (28.1%) | 111 (28.2%) |
(3) Yang-deficiency | 420 (39.0%) | 40 (18.1%) | 114 (29.2%) |
(4) Yin-deficiency | 439 (40.7%) | 31 (14.0%) | 94 (24.1%) |
(5) Phlegm-wetness | 444 (41.2%) | 40 (18.0%) | 79 (20.3%) |
(6) Wetness-heat | 411 (38.1%) | 35 (15.9%) | 82 (21.0%) |
(7) Blood-stasis | 432 (40.1%) | 44 (19.9%) | 103 (26.4%) |
(8) Qi-depression | 451 (41.9%) | 37 (16.7%) | 82 (20.9%) |
(9) Special diathesis | 371 (34.4%) | 36 (16.2%) | 64 (16.4%) |
(10) No body constitution | 15 (1.4%) | 2 (0.9%) | 8 (2.1%) |
Number of body constitution by CCMQ | |||
0 | 15 (1.4%) | 2 (0.9%) | 8 (2.0%) |
1 | 364 (33.7%) | 132 (58.2%) | 217 (53.7%) |
2 | 120 (11.1%) | 35 (14.7%) | 46 (11.4%) |
3 | 103 (9.5%) | 17 (7.6%) | 40 (9.9%) |
4 | 98 (9.1%) | 10 (4.4%) | 21 (5.2%) |
5 | 91 (8.4%) | 6 (2.7%) | 24 (5.9%) |
6 | 90 (8.3%) | 8 (3.6%) | 11 (2.7%) |
7 | 102 (9.4%) | 5 (2.2%) | 11 (2.7%) |
8 | 97 (9.0%) | 4 (1.8%) | 12 (3.0%) |
“No body constitution” means that all body constitutions are “NO.”
Table
Spearman item-scale correlations and scaling success rate of the CCMQ.
Baseline |
||
---|---|---|
CCMQ diagnosis | Item-scale correlation | Scaling success rate† |
(1) Gentleness | 0.377–0.686 | 100% |
(2) Qi-deficiency | 0.433–0.717 | 87.5% |
(3) Yang-deficiency | 0.517–0.811 | 85.7% |
(4) Yin-deficiency | 0.475–0.701 | 100% |
(5) Phlegm-wetness | 0.531–0.679 | 87.5% |
(6) Wetness-heat | 0.563–0.666 | 100% |
(7) Blood-stasis | 0.460–0.681 | 85.7% |
(8) Qi-depression | 0.488–0.820 | 85.7% |
(9) Special diathesis | 0.488–0.712 | 100% |
All item-scale Spearman correlations were significant (
†Scaling success means the item and hypothesized-scale correlation was higher than all items and competing-scale correlations. This rate was the proportion of total number of comparisons for all the items in each scale that was successful.
Item 53 “are you capable to adapt to the external changes of the natural and social environment?” of the gentleness scale had an item-scale correlation <0.4.
Confirmatory factor analysis (CFA) (Table
Confirmatory factor analysis of CCMQ.
Factor 1 | Factor 2 | Factor 3 | ||||||
---|---|---|---|---|---|---|---|---|
Gentleness | Qi-deficiency | Yang-deficiency | ||||||
Variable | Factor loading |
|
Variable | Factor loading |
|
Variable | Factor loading |
|
|
0.497 | 0.247 |
|
|
0.485 |
|
0.722 | 0.521 |
|
|
0.485 |
|
0.694 | 0.481 |
|
0.739 | 0.546 |
|
|
0.441 |
|
0.713 | 0.508 |
|
0.755 | 0.57 |
|
0.804 | 0.79 |
|
0.678 | 0.46 |
|
1.253 | 0.9 |
|
0.474 | 0.9 |
|
0.449 | 0.202 |
|
0.466 | 0.417 |
|
|
0.206 |
|
|
0.441 |
|
0.651 | 0.424 |
|
0.224 | 0.05 |
|
0.224 | 0.217 |
|
0.625 | 0.391 |
|
|
0.235 |
|
0.362 | 0.131 | |||
| ||||||||
Factor 4 | Factor 5 | Factor 6 | ||||||
Yin-deficiency | Phlegm-wetness | Wetness-heat | ||||||
Variable | Factor loading |
|
Variable | Factor loading |
|
Variable | Factor loading |
|
| ||||||||
|
0.602 | 0.362 |
|
0.697 | 0.486 |
|
0.539 | 0.29 |
|
0.658 | 0.433 |
|
0.713 | 0.509 |
|
0.568 | 0.322 |
|
0.507 | 0.257 |
|
0.523 | 0.274 |
|
0.582 | 0.338 |
|
0.665 | 0.443 |
|
0.588 | 0.346 |
|
0.612 | 0.374 |
|
0.651 | 0.423 |
|
0.689 | 0.475 |
|
0.591 | 0.349 |
|
0.629 | 0.395 |
|
0.456 | 0.208 |
|
0.554 | 0.307 |
|
0.651 | 0.424 |
|
0.475 | 0.226 | |||
|
0.5 | 0.25 |
|
0.605 | 0.366 | |||
| ||||||||
Factor 7 | Factor 8 | Factor 9 | ||||||
Blood-stasis | Qi-depression | Special diathesis | ||||||
Variable | Factor loading |
|
Variable | Factor loading |
|
Variable | Factor loading |
|
| ||||||||
|
|
0.206 |
|
1.581 | 0.79 |
|
0.466 | 0.217 |
|
0.564 | 0.318 |
|
0.79 | 0.624 |
|
0.59 | 0.349 |
|
0.674 | 0.454 |
|
0.806 | 0.65 |
|
0.689 | 0.475 |
|
0.443 | 0.196 |
|
0.826 | 0.682 |
|
0.689 | 0.475 |
|
0.672 | 0.451 |
|
0.636 | 0.404 |
|
0.605 | 0.365 |
|
0.599 | 0.359 |
|
0.676 | 0.458 |
|
0.621 | 0.386 |
|
0.651 | 0.424 |
|
0.7 | 0.49 | |||
|
0.612 | 0.374 | ||||||
| ||||||||
Confirmatory factor analysis model (Goodness of fit statistics for CCMQ) | ||||||||
SB |
df |
|
RMSEA | 90% CI for RMSEA | SRMR | CFI | TLI | IFI |
| ||||||||
7027.2 | 1668 | <0.001 | 0.0563 | (0.0549, 0.0576) | 0.0626 | 0.969 | 0.967 | 0.969 |
SB
The correlations between the scale scores of the CCMQ and SF-12v2 are shown in Table
Correlations between the domain scores of the CCMQ and SF-12v2.
|
Domains of SF-12 | |||||||||
---|---|---|---|---|---|---|---|---|---|---|
PF | RP | BP | GH | VT | SF | RE | MH | PCS | MCS | |
(1) Gentleness | 0.296 | 0.464 | 0.442 | 0.471 | 0.606 | 0.442 | 0.512 | 0.508 | 0.368 | 0.565 |
(2) Qi-deficiency | −0.317 | −0.463 | −0.420 | −0.394 | −0.509 | −0.417 | −0.483 | −0.452 | −0.362 | −0.499 |
(3) Yang-deficiency | −0.215 | −0.350 | −0.338 | −0.294 | −0.367 | −0.326 | −0.348 | −0.304 | −0.294 | −0.351 |
(4) Yin-deficiency |
|
|
|
|
|
|
|
|
|
|
(5) Phlegm-wetness |
|
|
|
|
|
|
|
|
|
|
(6) Wetness-heat |
|
|
|
|
|
|
|
|
|
|
(7) Blood-stasis |
|
|
|
|
|
|
|
|
|
|
(8) Qi-depression |
|
|
|
|
|
|
|
|
|
|
(9) Special diathesis |
|
|
|
|
|
|
|
|
|
|
PF: physical functioning; RP: role limitation due to physical problems; BP: bodily pain; GH: general health; VT: vitality; SF: social functioning; RE: role limitation due to emotional problems; MH: mental health; PCS: physical component score; MCS: mental component score.
All spearman correlations are significant,
SF-12v2 scores by body constitutions types of CCMQ.
Baseline |
SF12V2 mean (sd) | |||||||||
---|---|---|---|---|---|---|---|---|---|---|
PF | RP | BP | GH | VT | SF | RE | MH | PCS | MCS | |
(1) Gentleness | 90.8 (20.7) | 88.1 (21.2) | 84.0 (24.8) | 45.9 (21.4) | 71.3 (23.4) | 93.3 (15.5) | 91.2 (16.4) | 81.8 (16.2) | 49.8 (8.2) | 57.2 (8.2) |
(2) Qi-deficiency | 78.1 (27.4) | 67.5 (27.8) | 60.8 (28.6) | 29.2 (19.4) | 46.2 (24.9) | 75.2 (26.5) | 69.1 (25.8) | 62.1 (20.1) | 43.9 (10.5) | 46.6 (10.6) |
(3) Yang-deficiency | 78.0 (28.0) | 65.7 (29.0) | 59.4 (29.1) | 28.6 (19.6) | 45.8 (26.0) | 73.5 (26.8) | 68.8 (26.0) | 62.9 (21.1) | 43.3 (10.5) | 46.7 (10.7) |
(4) Yin-deficiency | 78.6 (27.1) | 66.2 (27.8) | 60.2 (28.9) | 27.9 (19.4) | 46.7 (25.9) | 75.1 (26.5) | 67.2 (25.8) | 61.4 (19.8) | 43.8 (10.4) | 46.2 (10.6) |
(5) Phlegm-wetness | 76.5 (28.4) | 65.4 (27.8) | 58.9 (28.2) | 27.9 (18.8) | 45.4 (25.1) | 74.0 (26.9) | 67.7 (26.4) | 61.8 (19.9) | 43.0 (10.6) | 46.5 (10.9) |
(6) Wetness-heat | 81.0 (26.6) | 68.5 (27.9) | 62.3 (28.3) | 30.3 (19.5) | 47.4 (25.3) | 75.3 (26.6) | 70.5 (25.9) | 63.9 (19.0) | 44.5 (10.2) | 47.1 (10.6) |
(7) Blood-stasis | 77.9 (27.1) | 66.2 (27.9) | 59.6 (27.5) | 27.5 (18.8) | 45.5 (25.2) | 74.5 (26.5) | 67.8 (26.5) | 61.2 (20.4) | 43.5 (10.1) | 46.2 (10.7) |
(8) Qi-depression | 78.1 (27.4) | 67.7 (27.8) | 63.1 (28.7) | 29.6 (19.9) | 48.5 (25.2) | 75.1 (26.8) | 69.4 (26.8) | 62.7 (20.2) | 44.1 (10.5) | 46.9 (10.8) |
(9) Special diathesis | 77.7 (27.2) | 64.9 (28.3) | 58.9 (27.9) | 26.7 (17.4) | 43.9 (25.3) | 71.9 (27.3) | 64.6 (25.4) | 57.4 (19.2) | 43.8 (10.2) | 44.3 (10.3) |
PF: physical functioning; RP: role limitation due to physical problems; BP: bodily pain; GH: general health; VT: vitality; SF: social functioning; RE: role limitation due to emotional problems; MH: mental health; PCS: physical component score; MCS: mental component score.
Difference between mean SF-12v2 scores of gentleness and imbalanced physiological constitution groups are statistically significant by independent
CMP diagnoses were used as a gold standard to assess the accuracy of the BC type classification by the CCMQ. Table
Table
The internal reliability of Cronbach’s alpha and intraclass correlation were all satisfactory (>0.6) (Table
Cronbach's alpha and ICC of the CCMQ.
Cronbach's alpha |
ICC (95% CI) |
|
---|---|---|
CCMQ | 0.89 | |
(1) Gentleness | 0.72 | 0.78 (0.74, 0.82) |
(2) Qi-deficiency | 0.76 | 0.82 (0.78, 0.85) |
(3) Yang-deficiency | 0.82 | 0.88 (0.86, 0.90) |
(4) Yin-deficiency | 0.75 | 0.80 (0.75, 0.83) |
(5) Phlegm-wetness | 0.74 | 0.78 (0.74, 0.82) |
(6) Wetness-heat | 0.66 | 0.76 (0.71, 0.80) |
(7) Blood-stasis | 0.67 | 0.71 (0.65, 0.76) |
(8) Qi-depression | 0.84 | 0.85 (0.82, 0.88) |
(9) Special diathesis | 0.74 | 0.81 (0.77, 0.85) |
Reliability of diagnosis after 2-week followup of CCMQ.
At baseline | After 2-week followup | Kappa statistics | ||
---|---|---|---|---|
No | Yes | |||
CCMQ diagnosis | ||||
| ||||
(1) Gentleness |
No |
96 (60.0%) | 64 (40.0%) | 0.318 |
Yes |
11 (19.0%) | 47 (81.0%) | ||
(2) Qi-deficiency |
No |
112 (96.6%) | 4 (3.4%) | 0.531 |
Yes |
47 (44.3%) | 59 (55.7%) | ||
(3) Yang-deficiency |
No |
142 (95.9%) | 6 (4.1%) | 0.488 |
Yes |
37 (52.9%) | 33 (47.1%) | ||
(4) Yin-deficiency |
No |
141 (95.3%) | 7 (4.7%) | 0.346 |
Yes |
46 (65.7%) | 24 (34.3%) | ||
(5) Phlegm-wetness |
No |
133 (94.3%) | 8 (5.7%) | 0.397 |
Yes |
46 (59.0%) | 32 (41.0%) | ||
(6) Wetness-heat |
No |
139 (93.3%) | 10 (6.7%) | 0.340 |
Yes |
44 (63.8%) | 25 (36.2%) | ||
(7) Blood-stasis | No |
135 (92.5%) | 11 (7.5%) | 0.411 |
Yes |
40 (55.6%) | 32 (44.4%) | ||
(8) Qi-depression |
No |
133 (95.0%) | 7 (5.0%) | 0.373 |
Yes |
49 (62.0%) | 30 (38.0%) | ||
(9) Special diathesis |
No |
142 (94.0%) | 9 (6.0%) | 0.372 |
Yes |
42 (61.8%) | 26 (38.2%) |
Chinese medicine practitioners diagnosis against CCMQ classification of body constitutions.
CMP | Sensitivity | Specificity | |||
---|---|---|---|---|---|
Yes | No | ||||
CCMQ | |||||
| |||||
(1) Gentleness | Yes |
34 | 170 | 54.8 | 82.7 |
No |
28 | 813 | |||
(2) Qi-deficiency | Yes |
69 | 524 | 51.9 | 42.7 |
No |
64 | 391 | |||
(3) Yang-deficiency | Yes |
65 | 347 | 48.5 | 61.9 |
No |
69 | 564 | |||
(4) Yin-deficiency | Yes |
101 | 328 | 44.5 | 60.0 |
No |
126 | 491 | |||
(5) Phlegm-wetness | Yes |
82 | 350 | 43.4 | 59.2 |
No |
107 | 507 | |||
(6) Wetness-heat | Yes |
45 | 362 | 42.9 | 61.6 |
No |
60 | 581 | |||
(7) Blood-stasis | Yes |
49 | 372 | 44.1 | 60.2 |
No |
62 | 563 | |||
(8) Qi-depression | Yes |
40 | 400 | 61.5 | 59.2 |
No |
25 | 580 | |||
(9) Special diathesis | Yes |
15 | 345 | 75.0 | 66.4 |
No |
5 | 681 |
CCMQ and SF-12v2 scores by gender and age groups.
Gender | Age group | |||||||||
---|---|---|---|---|---|---|---|---|---|---|
Male |
Female |
18–40 |
41–64 |
>65 |
||||||
Mean | SD | Mean | SD | Mean | SD | Mean | SD | Mean | SD | |
CCMQ | ||||||||||
| ||||||||||
(1) Gentleness*† | 66.9 | 15.6 | 59.0 | 16.7 | 58.5 | 16.4 | 61.6 | 16.8 | 68.8 | 14.9 |
(2) Qi-deficiency*† | 29.3 | 15.9 | 35.5 | 17.8 | 37.7 | 17.1 | 33.6 | 17.2 | 22.5 | 14.9 |
(3) Yang-deficiency*† | 18.1 | 16.7 | 30.9 | 22.2 | 31.5 | 21.3 | 26.1 | 21.4 | 17.7 | 18.5 |
(4) Yin-deficiency*† | 21.8 | 15.9 | 28.7 | 16.5 | 31.5 | 16.3 | 26.2 | 16.4 | 15.6 | 12.7 |
(5) Phlegm-wetness*† | 23.2 | 16.4 | 28.3 | 17.6 | 29.6 | 17.2 | 27.5 | 17.5 | 16.7 | 14.2 |
(6) Wetness-heat† | 26.4 | 16.3 | 26.3 | 17.3 | 33.4 | 17.1 | 24.3 | 15.7 | 15.5 | 13.9 |
(7) Blood-stasis*† | 20.0 | 13.6 | 31.1 | 16.1 | 31.0 | 16.3 | 28.0 | 16.3 | 18.4 | 11.5 |
(8) Qi-depression*† | 20.6 | 17.1 | 29.6 | 18.9 | 31.6 | 18.2 | 26.5 | 18.9 | 15.2 | 14.9 |
(9) Special diathesis*† | 21.8 | 16.0 | 25.6 | 17.4 | 29.1 | 17.6 | 23.7 | 16.4 | 15.6 | 14.3 |
SF-12v2 | ||||||||||
(1) Physical component score*† | 48.6 | 8.5 | 45.2 | 10.3 | 47.6 | 9.0 | 45.8 | 9.9 | 44.1 | 11.8 |
(2) Mental component score | 51.4 | 9.9 | 49.9 | 10.8 | 47.6 | 10.0 | 50.9 | 10.4 | 55.7 | 10.1 |
†Significant difference between the patients with age by Kruskal-Wallis
Table
Change of CCMQ at baseline and after 3–6-month followup.
Baseline | After 3–6-month followup | Body constitution at baseline | Body constitution after 3–6-month followup | ||||
---|---|---|---|---|---|---|---|
Mean | SD | Mean | SD | Yes | No | ||
(1) Gentleness*† | 60.1 | 16.7 | 67.4 | 18.3 | Yes |
54 (79.4%) | 14 (20.6%) |
No |
91 (27.6%) | 239 (72.4%) | |||||
(2) Qi-deficiency*† | 35.0 | 17.9 | 23.9 | 18.2 | Yes |
109 (47.0%) | 123 (53.0%) |
No |
8 (4.7%) | 163 (95.3%) | |||||
(3) Yang-deficiency*† | 27.6 | 22.1 | 22.1 | 21.2 | Yes |
94 (60.3%) | 62 (39.7%) |
No |
25 (10.3%) | 217 (89.7%) | |||||
(4) Yin-deficiency*† | 27.1 | 16.6 | 20.6 | 14.8 | Yes |
80 (50.3%) | 79 (49.7%) |
No |
18 (7.5%) | 222 (92.5%) | |||||
(5) Phlegm-wetness*† | 28.2 | 17.4 | 18.9 | 15.2 | Yes |
72 (40.0%) | 108 (60.0%) |
No |
10 (4.6%) | 209 (95.4%) | |||||
(6) Wetness-heat*† | 26.7 | 17.3 | 19.7 | 15.1 | Yes |
70 (45.5%) | 84 (54.5%) |
No |
16 (6.5%) | 229 (93.5%) | |||||
(7) Blood-stasis*† | 28.5 | 15.9 | 22.5 | 15.2 | Yes ( |
86 (51.2%) | 82 (48.8%) |
No |
20 (8.7%) | 211 (91.3%) | |||||
(8) Qi-depression*† | 28.3 | 19.4 | 19.1 | 17.7 | Yes |
75 (42.1%) | 103 (57.9%) |
No |
12 (5.4%) | 211 (94.6%) | |||||
(9) Special diathesis*† | 25.4 | 17.2 | 17.8 | 13.1 | Yes |
55 (37.9%) | 90 (62.1%) |
No |
13 (5.1%) | 241 (94.9%) | |||||
| |||||||
SF-12v2 | |||||||
(1) Physical component score† | 46.0 | 10.7 | 48.6 | 9.6 | |||
(2) Mental component score† | 49.9 | 10.9 | 52.5 | 10.6 |
†Significant difference between baseline and 3–6-month followup by McNemar-Bowker test.
The results confirmed the need to evaluate the validity of a psychometric measure before its application to a different population. Some items of the CCMQ were not clear to Chinese people in Hong Kong even though the instrument was developed in Chinese. Some concepts such as “shortness of breath” (
The CCMQ was able to classify 98.6% subjects into at least one type of BC supporting its feasibility and acceptability. Only around 20% subjects were classified to have gentleness BC type, which was lower than the 32.1% found in population studies in China [
There was no floor or ceiling effect in the CCMQ scale suggesting that the instrument could be useful in monitoring improvement or deterioration in a particular BC type over time or in response to interventions [
There were positive correlations between gentleness BC type with SF-12v2 scores but reverse correlations between the other imbalanced BC types. People with gentleness BC type are considered the healthiest; therefore, they had the highest SF-12 scores. The results were good evidence on not only the concurrent validity of the CCMQ but also the importance of imbalanced BC types and the concept of “Not Yet Ill.”
Using the pragmatic diagnosis by CMP as the gold standard, the sensitivity and specificity of the CCMQ in predicting the BC type were lower than expected. A previous study also showed similar results [
The reliability coefficients of the CCMQ scales were comparable to the established SF-12v2 Health Survey, meaning that the CCMQ scales were consistent and reproducible. However, there was relatively poor reproducibility in the classification of the same BC type on retest after 2 weeks. Although the kappa values were rather low, 40% of subjects classified to gentleness BC type still had the same classification after two weeks, supporting fair reproducibility. The reproducibility of the specific imbalanced BC types was rather low, probably because of the overlapping BC types. The use of a single cut-off score, which may result in the change in the classification with a slight change in the response to scale items. It was also possible that subjects could have a change in their conditions although we only included patients whose reason for visiting the clinic was routine followup of their chronic conditions.
The CCMQ (HK versions) showed a difference in the severity of BC types between gender and age groups, supporting their sensitivity. It is likely that it could also differentiate between the healthy, not yet ill, and ill subjects. Further studies on people with different conditions should be carried out to establish its sensitivity in detecting difference in BC types associated with specific illnesses.
This study was the first to investigate and confirm the responsiveness of CCMQ to change in BC type classification and severity. The results also supported the TCM theory that BC type was not static and could change with season and may be subject for health promotion. It was good to note that a higher proportion of subjects changed back to gentleness BC type, and more people changed from “positive” to “negative” for any particular imbalanced BC types on followup. This could be related to an improvement in the health of these clinic patients after their consultations or a seasonal effect. In TCM theory, certain BC types occur more frequently or may become more severe during each season, for example, phlegm-wetness is expected to be more common in the summer than winter, while patients with Yang-deficiency will get more severe during winter but not in summer. Further epidemiological studies on the general population should be carried out to determine the effect of season on BC types.
The subjects were convenient patient samples, and the response rate in the psychometric study was relatively low, which might have biased the distributions of BC types. However, our study samples included people from all age groups and both genders, so the results on validity and reliability of CCMQ should be generalizable to other Chinese people in Hong Kong. The CCMQ were administered by an interviewer to all subjects, so the results might not be applicable to self-administration. No standardization of the CMP diagnosis of BC type was made, which might have affected the accuracy of the predictive sensitivity and specificity of the CCMQ. Better standardization of the CMP diagnosis and assessment of each subject by more than one CMP should be considered in future studies on the accuracy of CCMQ.
The CCMQ was adapted to a HK version with some changes to the wording of four items for Cantonese speaking Chinese people in Hong Kong. The construct validity, reliability, sensitivity, and responsiveness of the CCMQ scales were satisfactory. The CCMQ was able to classify the majority of people into one or more BC types. The instrument is useful in differentiating people with the gentleness BC type from those with imbalanced BC types, but the significance of more than one imbalanced BC types needs to be confirmed. One weakness is the relatively low sensitivity and specificity in predicting the CMP BC type diagnosis and low reproducibility in specific BC type classification. The CCMQ has the potential applications in population-based epidemiological studies as well as clinical trials.
Further research should also be done to explore whether the CCMQ can be shortened to improve its acceptability. Calibration of the cut-off scores for the definition of specific BC type should be carried out against better assured gold standards. The performance as an outcome measure in health promotion interventions should be evaluated.
The authors would like to acknowledge the funding from the Hong Kong Hospital Authority, the collaboration from Tung Wah Group of Hospitals for patient recruitment, and the support from the Danny D. B. Ho endowed Professorship in this study. Special thanks to all patients and Chinese medicine practitioners who participated in this study. Ethical approval: HKU/HA HKW IRB (UW 10-255).