Cardiovascular diseases (CVDs) remain a leading contributor to morbidity and mortality worldwide and exert a significant toll on health systems [
Cardiac rehabilitation (CR) is a comprehensive outpatient chronic disease management program delivering all guideline recommendations for secondary prevention [
Of all countries globally, the second greatest unmet need for CR exists in China [
Validated scales such as the Cardiac Rehabilitation Barriers Scale (CRBS) are key to identifying these barriers at multiple levels [
Accordingly, the aim of this study was to (1) rigorously translate and cross-culturally adapt CRBS to Mandarin (simplified Chinese) using best practices and then (2) psychometrically validate the translation. This involved assessing factor structure (including confirmatory factor analysis), reliability (internal), and validity (criterion and construct). The final aim (3) was to identify the main barriers in the population.
This was a multimethod study.
The multistep process of translation and cultural adaptation was done in accordance with best practices [
Next, a review committee which was comprised of five experts in the field of CR (two cardiomedical experts, one rehabilitation expert, and two nursing professors) was engaged in a Delphi process. There were two rounds of consultations to verify semantic and cross-cultural relevance of the items. Finally, the back-translated and revised version of the scale was then compared with the original version to consider conceptual discrepancies, after which the Chinese/Mandarin version of CRBS was finalized.
The 5 experts were asked to rate the content validity in both rounds, to establish that CRBS-C/M had an appropriate sample of items for CR barriers; the content validity index (CVI) for the items and scale were computed.
Participants for this study were recruited from outpatient cardiology clinics and wards in 11 hospitals in Shanghai, China. Four research nurses (in groups of 2) went to the hospitals between September and November 2017 on weekdays to collect data. Participants were first briefly informed of the purpose and significance of the study, after which informed consent was obtained. The participants then completed the paper-based questionnaire on site.
Two of the 11 hospitals have CR programs to which patients could be referred locally. The CR involved structured, supervised exercise sessions and patient education. The latter was delivered via hard copy education materials (including text and pictures) 1-1 to the patient.
Patients diagnosed with new myocardial infarction (including silent infarcts identified through an electrocardiogram) or acute coronary syndrome, chronic stable angina, heart failure, or having had coronary artery bypass surgery, percutaneous coronary intervention, and/or valvular surgery were eligible for the study. The inclusion criterion was age 18-75 years. Those with severe comorbidities were excluded. If the participants had low literacy and hence could not read or write in Mandarin, the research nurse would read the questionnaire item by item and denote their responses.
The survey was in Mandarin. The survey commenced with items regarding sociodemographic (e.g., age, sex, marital status, living arrangements, education, work status, and healthcare coverage) as well as clinical (e.g., diagnosis/procedures, duration of disease, disease severity, risk factors, comorbidities, and heart health behaviors) characteristics. To assess criterion validity, CR participation (any; yes/no) was collected via self-report as well.
The CRBS scale evaluated patients’ perception of the degree to which patient, provider, and health system-level barriers affect their CR enrolment and participation (i.e., all items applicable to enrollees and nonenrollees alike). The English version consists of 21 items (barriers) related to 4 subscales: perceived need/healthcare system factors, logistical barriers, work/time conflicts, and comorbidities/functional status [
Where participants completed more than 80% of the items, a mean total score was computed. Subscale scores were also computed based on the results of the factor analysis.
In addition to the sociodemographic and clinical characteristics assessed above, 2 psychometrically validated scales were administered to assess construct validity. The Hospital Anxiety and Depression Scale (HADS) is a 14-item questionnaire used to screen for psychosocial distress in general hospital outpatients [
The Cardiac Rehabilitation Information Awareness Questionnaire (CRIAQ) was developed by Jing [
The Statistical Package for Social Sciences v. 23 (SPSS Inc., Chicago, IL, USA) was used for all data analysis, except that the lavaan version (0.6-5) in R 3.6.2 was used for confirmatory factor analysis (CFA). The level of significance for all tests was set at 0.05. A descriptive examination of participant characteristics, as well as CRBS and CRIAQ items, was performed.
For the psychometric validation, first exploratory factor analysis (EFA) was performed. Factor extraction was conducted using the principal component method with varimax rotation. The number of factors to extract was determined by examining the scree plots and considering factors with eigenvalues greater than 1.0.
CFA was then done to verify the factor structure obtained from EFA. To determine adequacy of fit, indices considered were the model chi-square/df index, the comparative fit index (CFI), the Tucker-Lewis index (TLI), the Akaike information criterion (AIC), the Bayesian information criterion (BIC), the standardized root mean square residual (SRMSR), and the root mean square error of approximation (RMSEA);
To determine the internal consistency, Cronbach’s
To assess criterion validity, differences in CRBS item, subscale, and total scores by CR participation were tested using Student’s independent samples
Following translations and harmonization of CRBS to Mandarin, through the Delphi process, the expert health professionals deemed all 21 questions in the original CRBS version applicable to the Chinese context, but suggested more detail be added to some of the questions. Hence, slight changes were made to some of the questions. For example, to CRBS item 1 “…of distance,” they added “(e.g., not located in your area, too far to travel).” CRBS 18 was modified from “I can manage on my own” to “I can manage my heart problem on my own.” The committee also agreed to revise some of the items to aid clarity. Modifications were made to CRBS items 2-6, 10-11, 17, and 21 without changing their semantic value. They also considered adding some additional items (i.e., duration of program, duration of sessions, did not perceive benefit from sessions, and went to a few sessions and feel they can do the exercise independently); however, they would only be relevant to CR enrollees and therefore they were not incorporated. The I-CVIs ranged from 0.80 to 1.00, and the S-CVI was 0.92, which establishes that the Chinese version of CRBS has acceptable content validity. The final C/M survey is shown in the online supplement.
The sample was comprised of 380 participants, of which 19 (5.0%) participated in CR (Table
Sociodemographic and clinical characteristics of study participants by CR participation, and association with total CRBS score.
Total | Participated in CR | Did not participate | |||
---|---|---|---|---|---|
Age | 0.079 | 0.240 | |||
Sex (% female) | 128 (37%) | 8 (42.1%) | 120 (37.0%) | 0.657 | 0.004 |
Marital status (% married) | 331 (86%) | 18 (94.7%) | 309 (95.4%) | 0.899 | 0.875 |
Living status (% alone) | 59 (15.3%) | 1 (5.3%) | 58 (17.8%) | 0.157 | 0.010 |
Caregivers | 0.001 | 0.089 | |||
Family (e.g., spouse and child) | 193 (50.2%) | 9 (47.4%) | 180 (55.4%) | ||
Self | 153 (39.7%) | 10 (52.6%) | 143 (44.0%) | ||
Nurse | 2 (0.5%) | 0 | 2 (0.6%) | ||
Nationality (% Han) | 346 (89.9%) | 19 (100%) | 323 (99.4%) | 0.732 | 0.241 |
Education | 0.367 | 0.152 | |||
Junior high school and below | 159 (46.2%) | 8 (42.1%) | 151 (46.5%) | ||
Technical secondary school/senior high school | 133 (38.7%) | 6 (31.6%) | 127 (39.1%) | ||
College degree | 52 (15.1%) | 5 (26.3%) | 47 (14.5%) | ||
Work status (% working) | 54 (15.7%) | 6 (31.6%) | 48 (14.8%) | 0.051 | 0.467 |
Residence (% city or town) | 327 (84.9%) | 19 (100%) | 305 (94.1%) | 0.277 | 0.020 |
Family income | 0.029 | 0.112 | |||
(% >40001RMB)‡ | 191 (49.6%) | 10 (52.6%) | 181 (55.7%) | ||
≤40000RMB | 153 (50.4%) | 9 (47.4%) | 144 (44.3%) | ||
Healthcare coverage | 0.306 | 0.263 | |||
Insurance or government | 330 (85.7%) | 19 (100%) | 307 (94.8%) | ||
Out-of-pocket | 17 (4.4%) | 0 | 17 (5.2%) | ||
Duration of CHD | 0.975 | 0.839 | |||
<1 year | 127 (33%) | 7 (36.8%) | 120 (37.2%) | ||
1-5 years | 104 (27%) | 5 (26.3%) | 96 (29.7%) | ||
>5 years | 114 (29.6%) | 7 (36.8%) | 106 (32.8%) | ||
Diagnosis | 0.041 | <0.001 | |||
Silent infarction | 159 (46.6%) | 7 (36.8%) | 152 (47.2%) | ||
Myocardial infarction | 91 (26.7%) | 5 (26.3%) | 86 (26.7%) | ||
Other | 40 (11.7%) | 4 (21.1%) | 36 (11.2%) | ||
Unstable angina | 36 (10.6%) | 0 | 36 (11.2%) | ||
Stable angina | 15 (4.4%) | 3 (15.8%) | 12 (3.7%) | ||
PCI (% yes) | 264 (78.3%) | 8 (42.1%) | 256 (80.5%) | <0.001 | 0.757 |
CABG (% yes) | 14 (3.6%) | 6 (31.6%) | 8 (2.6%) | <0.001 | <0.001 |
Medication adherence (% regularly taking) | 304 (79%) | 18 (94.7%) | 285 (95%) | 0.394 | 0.553 |
NYHA class | 0.980 | 0.065 | |||
I | 163 (42.3%) | 9 (47.4%) | 154 (47.5%) | ||
II | 143 (37.1%) | 8 (42.1%) | 135 (41.7%) | ||
III | 35 (9.1%) | 2 (10.5%) | 32 (9.9%) | ||
IV | 3 (0.8%) | 0 | 3 (0.9%) | ||
BMI | 0.920 | 0.032 | |||
Tobacco use | 0.261 | 0.002 | |||
Never used | 176 (51.2%) | 12 (63.2%) | 164 (50.5%) | ||
Former user | 101 (29.4%) | 6 (31.6%) | 95 (29.2%) | ||
Current user | 67 (19.5%) | 1 (5.3%) | 66 (20.3%) | ||
Hypertension (% yes) | 245 (71.4%) | 15 (78.9%) | 230 (71%) | 0.455 | 0.071 |
Diabetes (% yes) | 124 (36.2%) | 9 (47.4%) | 115 (35.5%) | 0.295 | 0.639 |
Family history of CVD | 146 (42.6) | 10 (52.6%) | 136 (42%) | 0.361 | 0.042 |
Stroke | 19 (4.9%) | 1 (5.3%) | 18 (5.6%) | 0.957 | 0.764 |
Renal insufficiency | 11 (2.9%) | 0 | 11 (3.4%) | 0.414 | 0.793 |
Transient ischemic attack | 4 (1.0%) | 0 | 4 (1.2%) | 0.626 | 0.169 |
Peripheral vascular disease | 6 (1.6%) | 1 (5.3%) | 5 (1.5%) | 0.229 | 0.279 |
Harmful use of alcohol (% ≥2 drinks/day) | 2 (0.5%) | 0 | 2 (0.6%) | 0.766 | 0.731 |
Regular exercise (% ≥3 times/wk for ≥30 min) | 200 (52%) | 18 (94.7%) | 182 (56.0%) | 0.001 | <0.001 |
Monthly sodium intake§ | 0.050 | 0.001 | |||
<120 g | 22 (5.7%) | 0 | 22 (6.8%) | ||
120-179 g | 229 (59.5%) | 14 (73.7%) | 214 (65.8%) | ||
>180 g | 94 (24.4%) | 5 (26.4%) | 89 (27.4%) | ||
Daily fruit intake° | 0.533 | 0.287 | |||
<50 g | 42 (10.9%) | 1 (12.5%) | 40 (20.1%) | ||
50-200 g | 151 (39.2%) | 6 (87.5%) | 142 (71.3%) | ||
>200 g | 17 (4.4%) | 0 | 17 (8.5%) | ||
HADS | |||||
Depressive symptoms | 0.323 | 0.227 | |||
Anxiety | 0.525 | 0.532 | |||
CR information awareness | <0.001 | <0.001 |
‡
Cardiac Rehabilitation Information Awareness Questionnaire responses in those not participating in CR,
Item | Frequency (%) |
---|---|
(1) Have you ever heard of cardiac rehabilitation before this survey? | |
(a) Yes | 31 (9.5%) |
(b) No | 294 (90.5%) |
(2) Which of the following should be included in cardiac rehabilitation? (check all that apply)˄ | |
(a) Illness assessment | 11 (35.5%) |
(b) Lipid management | 17 (54.8%) |
(c) Hypertension management | 17 (54.8%) |
(d) Tobacco cessation/alcohol restriction | 16 (51.6%) |
(e) Diabetes management | 11 (35.5%) |
(f) Nutrition consultation | 10 (32.3%) |
(g) Weight management | 15 (48.4%) |
(h) Emotional regulation | 12 (38.7%) |
(i) Physical activity consultation | 9 (29.0%) |
(j) Exercise training | 12 (38.7%) |
(k) Sleep management | 14 (45.2%) |
(l) Regular follow-up | 14 (45.2%) |
(m) Medication review | 15 (48.4%) |
(n) I do not know | 7 (22.6%) |
(3) Which of the following are benefits of participating in cardiac rehabilitation? (check all that apply)˄ | |
(a) Cure coronary heart disease | 11 (35.5%) |
(b) Improve cardiac function | 19 (61.3%) |
(c) Reduce acute ischemic coronary events | 12 (38.7%) |
(d) Reduce mortality and recurrence of cardiovascular disease | 16 (51.6%) |
(e) Save medical expenses | 7 (22.6%) |
(f) Improve quality of life | 10 (32.3%) |
(g) Help to return to family and society | 8 (25.8%) |
(h) Improve mental health | 9 (29.0%) |
(i) I do not know | 7 (22.6%) |
(4) Which of the following risk factors can lead to the occurrence and development of coronary heart disease? (check all that apply) | |
(a) Hypertension | 259 (79.7%) |
(b) Hyperlipidemia | 208 (64.0%) |
(c) Hyperglycemia | 202 (62.2%) |
(d) Overweight/obesity | 162 (49.8%) |
(e) Tobacco use | 160 (49.2%) |
(f) Excessive drinking | 145 (44.6%) |
(g) Lack of exercise | 118 (36.3%) |
(h) Excessive psychological stress | 110 (33.8%) |
(i) I do not know | 37 (11.4%) |
(5) Do you agree that the occurrence and development of coronary heart disease can be controlled? | |
(a) Yes | 205 (63.1%) |
(b) No | 30 (9.2%) |
(c) I do not know | 88 (27.1%) |
(6) How frequently do coronary heart disease patients need to assess their lipids? | |
(a) Every 1-3 months | 24 (7.4%) |
(b) 3-6 months | 102 (31.4%) |
(c) 6-9 months | 49 (15.1%) |
(d) 9-12 months | 14 (4.3%) |
(e) Unknown | 135 (41.5%) |
(7) Which of the following practices help control blood lipids? (check all that apply) | |
(a) Reduce the intake of saturated fatty acids (e.g., lard, cream) | 251 (77.2%) |
(b) Reduce high cholesterol intake (e.g., animal guts and egg yolks) | 251 (77.2%) |
(c) Eat more foods that can lower low-density lipoprotein cholesterol (e.g., fish) | 170 (52.3%) |
(d) Weight loss | 150 (46.2%) |
(e) Increase physical activity | 136 (41.8%) |
(f) Take lipid-lowering drugs | 159 (48.9%) |
(g) I do not know | 26 (8.0%) |
(8) Do patients with coronary heart disease need to measure blood pressure frequently? | |
(a) Yes | 282 (86.8%) |
(b) No | 13 (4.0%) |
(c) I do not know | 29 (8.9%) |
(9) Which of the following statements about lowering blood pressure are true? (check all that apply) | |
(a) Stop the medication after your blood pressure is controlled | 259 (79.7%) |
(b) Stick to moderate exercise | 208 (64.0%) |
(c) Increase intake of fresh vegetables and fruits | 202 (62.2%) |
(d) Antihypertensive drugs require lifelong use | 162 (49.8%) |
(e) Reduce mental stress | 160 (49.2%) |
(f) Stay in bed mainly | 145 (44.6%) |
(g) Gradually reduce your salt intake until you eat less than 6 grams a day | 118 (36.3%) |
(h) Limit drinking | 110 (33.8%) |
(i) I do not know | 37 (11.4%) |
(10) If you are diagnosed with diabetes, which of the following measures will help reduce blood sugar? (check all that apply) | |
(a) Diet control | 253 (77.8%) |
(b) Proper exercise | 211 (64.9%) |
(c) Blood sugar monitoring | 191 (58.8%) |
(d) Receive diabetes-related health education | 117 (36.0%) |
(e) Use hypoglycemic drugs | 164 (50.5%) |
(f) I do not know | 49 (15.1%) |
(11) The dietary recommendations for patients with coronary heart disease are the following: (check all that apply) | |
(a) Do not overeat | 206 (63.4%) |
(b) Increase potassium-rich foods (e.g., nuts, beans, bananas, and kelp) | 111(34.2%) |
(c) Reduce intake of fatty foods | 275 (84.6%) |
(d) Eat more fresh fruits and vegetables | 258 (79.4%) |
(e) Increase dietary fiber intake | 205 (63.1%) |
(f) Reduce salt intake | 239 (73.5%) |
(g) I do not know | 19 (5.8%) |
(12) The waist circumference of patients with coronary heart disease should be less than how many centimeters? | |
(a) Male 90 cm/female 85 cm | 45 (13.8%) |
(b) Male 100 cm /female 95 cm | 49 (15.1%) |
(c) Male 110 cm/female 105 cm | 17 (5.2%) |
(d) Unknown | 213 (65.5%) |
(13) Do you know what the following measures should be taken against being overweight? (check all that apply) | |
(a) Dietary control, lower calorie intake | 289 (88.9%) |
(b) Strengthening exercises | 265 (81.5%) |
(c) Use weight-loss medication | 12 (3.7%) |
(d) I do not know | 12 (3.7%) |
(14) Have you ever heard of secondary prevention of heart disease? | |
(a) Yes | 24 (7.4%) |
(b) No | 300 (92.3%) |
(15) Have you heard about the need to use secondary preventive medications long-term in patients with coronary heart disease? | |
(a) Yes | 21 (6.5%) |
(b) No | 303 (93.2%) |
(16) Do excessive stress and anxiety affect the recovery of coronary heart disease patients? | |
(a) Yes | 267 (82.2%) |
(B) No | 19 (5.8%) |
(C) I do not know | 38 (11.7%) |
(17) Can exercise help reduce bad mood? | |
(a) Yes | 262 (80.6%) |
(b) No | 20 (6.2%) |
(c) I do not know | 42 (12.9%) |
(18) Do patients with coronary heart disease need structured exercise after their condition is stabilized? | |
(a) Yes | 301 (92.6%) |
(b) No | 6 (1.8%) |
(c) I do not know | 16 (4.9%) |
(19) Does proper exercise improve heart function? | |
(a) Yes | 296 (91.1%) |
(b) No | 6 (1.8%) |
(c) I do not know | 21 (6.5%) |
(20) Which of the following statements is true for patients with coronary heart disease? (check all that apply) | |
(a) The more the exercise, the better | 3 (0.9%) |
(b) Start with a small amount of exercise, increase gradually, and persist | 303 (93.2%) |
(c) It’s good to have a heavy sweat | 3 (0.9%) |
(d) Even if you have discomfort during exercise, continue to exercise | 5 (1.5%) |
(e) I do not know | 15 (4.6%) |
(21) Which of the following types of exercise do you think patients with coronary heart disease can choose? (check all that apply) | |
(a) Dumbbells | 9 (2.8%) |
(b) Jogging | 139 (42.8%) |
(c) Swimming | 56 (17.2%) |
(d) Walking | 306 (94.2%) |
(e) I do not know | Yes: 8 (2.5%) |
(22) Which of the following methods can help you judge that the intensity of your activity has reached a suitable moderate range? (check all that apply) | |
(a) Increase in heart rate by 20 to 30 beats/min after exercise compared to before exercise | 102 (31.4%) |
(b) Increase in heart rate by 40 to 50 beats/min after exercise compared to before exercise | 22 (6.8%) |
(c) Feel yourself breathing faster with exercise, but not short of breath | 83 (25.5%) |
(d) Dyspnea after exercise | 6 (1.8%) |
(e) The body sweats slightly after exercise | 200 (61.5%) |
(f) I do not know | 65 (20.0%) |
(23) How long do you think it is appropriate for patients with coronary heart disease to exercise at moderate intensity? | |
(a) 10 minutes or so | 58 (17.8%) |
(b) 30-90 minutes | 229 (70.5%) |
(c) More than 120 minutes | 2 (0.6%) |
(d) I do not know | 35 (10.8%) |
(24) How many times per week is it recommended for patients with coronary heart disease to do the above moderate-intensity exercise? | |
(a) <3 times | 31 (9.5%) |
(b) 3~7 times | 237 (72.9%) |
(c) >7 times | 21 (6.5%) |
(d) I do not know | 35 (10.8%) |
(25) Do you know what measures should be taken in case of chest discomfort or fatigue during exercise? (check all that apply) | |
(a) Keep exercising | 3 (0.9%) |
(b) Immediately stop and rest on site | 307 (94.5%) |
(c) If the symptoms are not relieved after rest, take a nitroglycerin pill under the tongue. After 5 minutes, if it is still not relieved, take another pill. If the symptom still persists, call first aid | 177 (54.5%) |
(d) I do not know | 4 (1.2%) |
(26) If someone has a sleep problem, can it affect the development of coronary heart disease? | |
(a) Yes | 259 (79.7%) |
(b) No | 16 (4.9%) |
(C) I do not know | 49 (15.1%) |
(27) When insomnia occurs, which of the following measures can be undertaken to improve sleep? (check all that apply) | |
(a) Identify the causes of insomnia and take targeted measures | 141 (43.4%) |
(b) Follow your doctor’s advice as soon as possible to use sedative sleeping pills | 128 (39.4%) |
(c) Professionals conduct psychological counseling | 100 (30.8%) |
(d) Appropriate exercise | 81 (24.9%) |
(e) I do not know | 82 (25.2%) |
(28) Is regular follow-up with your doctor necessary? | |
(a) Yes | 310 (95.4%) |
(b) No | 5 (1.5%) |
(c) I do not know | 9 (2.8%) |
(29) How many beats per minute is ideal for your heart rate? | |
(a) <55/min | 2 (0.6%) |
(b) 55~60/min | 89 (27.4%) |
(c) 60~70/min | 137 (42.2%) |
(d) >70/min | 40 (12.3%) |
(e) I do not know | 56 (17.2%) |
Total score ( |
˄Patients who answered “no” they had not heard of CR to question 1 were directed to skip to question 4. Therefore, the percentage reported is based on the available denominator for these items.
The structure of the scale was first assessed using principal component analysis. The Kaiser Meyer Olkin value was 0.867, and Bartlett’s test was significant (
Exploratory factor analysis of the Chinese/Mandarin version of CRBS,
Factor | |||||
---|---|---|---|---|---|
Item | CR need | External logistical factors | Time conflicts | Program and health system-level factors | Comorbidities/functional status |
18. … I can manage my heart problem on my own | 0.760 | ||||
6…I do not need cardiac rehab (e.g., feel well, heart problem treated, not serious) | 0.736 | ||||
21…I prefer to take care of my health alone, not in a group | 0.734 | ||||
17… many people with heart problems do not go, and they are fine | 0.703 | ||||
7…I already exercise at home, or in my community | 0.579 | 0.368 | |||
5…I did not know about cardiac rehab (e.g., doctor did not tell me about it) | 0.392 | 0.369 | |||
3…of transportation problems (e.g., access to car, public transportation) | 0.809 | ||||
1…of distance (e.g., not located in your area, too far to travel) | 0.765 | ||||
2…of cost (e.g., parking, gas) | 0.743 | ||||
8…severe weather | 0.559 | 0.376 | |||
11…of time constraints (e.g., too busy, inconvenient class time) | 0.821 | ||||
10…travel (e.g., holidays, business, cottage) | 0.800 | ||||
12…of work responsibilities | 0.719 | ||||
4…of family responsibilities (e.g., caregiving) | 0.415 | 0.467 | |||
19… I think I was referred, but the rehab program did not contact me | 0.745 | ||||
20…it took too long to get referred and into the program | 0.359 | 0.741 | |||
16…my doctor did not feel it was necessary | 0.613 | ||||
14…other health problems prevent me from going | 0.307 | 0.783 | |||
15…I am too old | 0.739 | ||||
13…I do not have the energy | 0.558 | ||||
9…I find exercise tiring or painful | 0.320 | 0.312 | 0.345 | 0.356 | |
Variance explained | 30.5% | 8.7% | 7.5% | 7.1% | 5.4% |
Eigenvalues | 6.41 | 1.84 | 1.59 | 1.50 | 1.14 |
Reliability | 0.823 | 0.820 | 0.773 | 0.674 | 0.676 |
CRBS: Cardiac Rehabilitation Barriers Scale.
CRBS item factor loadings are also shown in Table
The model fit indices for the CFA were found to be acceptable with a chi-square/df of 2.66, a TLI of 0.872, a CFI of 0.896, an SRMSR of 0.054, and an RMSEA of 0.066 (
With regard to criterion validity, Table
Mean CRBS item and subscale scores (standard deviation) by CR participation.
Item | Total sample ( | Participated in CR ( | Did not participate ( | |
---|---|---|---|---|
1…of distance (e.g., not located in your area, too far to travel) | 0.013 | |||
2…of cost (e.g., parking, gas) | <0.001 | |||
3…of transportation problems (e.g., access to car, public transportation) | 0.001 | |||
4…of family responsibilities (e.g., caregiving) | 0.001 | |||
5…I did not know about cardiac rehab (e.g., doctor did not tell me about it) | <0.001 | |||
6…I do not need cardiac rehab (e.g., feel well, heart problem treated, not serious) | 0.008 | |||
7…I already exercise at home, or in my community | 0.002 | |||
8…severe weather | 0.013 | |||
9…I find exercise tiring or painful | 0.001 | |||
10…travel (e.g., holidays, business, cottage) | 0.058 | |||
11…of time constraints (e.g., too busy, inconvenient class time) | 0.076 | |||
12…of work responsibilities | 0.187 | |||
13…I do not have the energy | <0.001 | |||
14…other health problems prevent me from going | 0.358 | |||
15…I am too old | 0.014 | |||
16…my doctor did not feel it was necessary | 0.047 | |||
17… many people with heart problems do not go, and they are fine | 0.013 | |||
18… I can manage my heart problem on my own | 0.003 | |||
19… I think I was referred, but the rehab program did not contact me | <0.001 | |||
20…it took too long to get referred and into the program | <0.001 | |||
21…I prefer to take care of my health alone, not in a group | 0.015 | |||
Total mean CRBS score | <0.001 | |||
Factor 1: CR need | <0.001 | |||
Factor 2: external logistical factors | <0.001 | |||
Factor 3: time conflicts | <0.001 | |||
Factor 4: program and health system-level factors | 0.001 | |||
Factor 5: comorbidities | 0.003 |
CRBS: Cardiac Rehabilitation Barriers Scale; CR: cardiac rehabilitation. Note:
With regard to construct validity, a significant negative association was observed between the CRIAQ and the CRBS scales (
The main barriers in the nonenrollees were distance, lack of awareness, weather, and transportation (Table
This study sought to rigorously translate, cross-culturally adapt, and psychometrically validate CRBS into Chinese/Mandarin. Through this process, all 21 items of the scale were retained, with slight adjustments made to some items to improve clarity. Factor analysis revealed five factors: CR need, external logistical factors, time conflicts, program and health system-level factors, and comorbidities/functional status. The subscales showed relatively good internal consistency (reliability). The significantly lower mean CRBS scores in patients who participated in CR establish the criterion validity of CRBS. Construct validity was demonstrated by significant associations between CRBS scores and many sociodemographic and clinical characteristics known to impact CR access, but surprisingly not anxious and depressive symptoms [
There are some differences in this C/M version of CRBS and the previously published one (named “C”) [
Second, in CRBS-C [
Finally, there were similarly 5 factors identified in the remaining 19 items, namely, time/work conflicts (items 12, 11, 13, and 10), cost/travel (items 1, 3, and 2), CR need (items 7, 18, and 6), physical/function limitations (items 15, 14, 16, and 8), and lack of CR knowledge (items 5, 17, 4, 20, and 9). These are quite similar, except that the latter was “program and health system-level factors” in our CRBS-C/M version. Although overall the psychometric properties of CRBS-C were favourable, some items were loaded onto factors in a way that would not be expected. For example, item 8 “severe weather” loaded onto the “Physical/functional limitation” factor (but on the “external logistical” factor in this version), and item 4 “family responsibilities” loaded onto the factor “Lack of CR knowledge” (but on the “time conflicts” factor in this version). Arguably, the item loadings overall on each factor are a better fit in the C/M version.
There are now 14 translations of CRBS, and with this version, and of those translations for which factor structure has been tested, 3 of them similarly have 5 rather than 4 factors as per the original version [
In this sample, 90% of participants had not even heard of CR before the study. Certainly, lack of awareness was a key barrier to CR utilization. Consistent with previous research [
The implications of this work are that now that we can validly and reliably assess CR barriers in Chinese samples, we can work to identify and mitigate them. One of the key barriers in nonenrollees was lack of awareness. Considering most patients were recruited at hospitals without CR programs, it is not surprising that their healthcare providers did not inform them about CR services; however, patients should have been educated about secondary prevention strategies at the least. As mentioned, with a burgeoning number of CR programs being built, this situation will change. Given that there is no reimbursement for CR services [
Other key barriers, namely, distance, weather, and transportation, could be mitigated with the provision of home-based CR, potentially exploiting technology such as WeChat which is so popular in China. Unfortunately, only 17% of the programs in China currently offered home-based services [
Finally, as shown in previous literature [
Caution is warranted in interpreting these results. First, only a small percentage (5%) of the sample participated in CR, and therefore results are primarily generalizable to those who do not access CR (which is the majority) [
The Chinese/Mandarin version of CRBS was developed, and its structure is comprised of five subscales, namely, perceived CR need, external logistical factors, time conflicts, program and health system-related factors, and comorbidities/functional status. It was found to have good psychometric properties, underscoring its reliability and validity in assessing barriers to CR utilization in Chinese individuals. This scale will be vital in identifying barriers so we can improve utilization in places with CR programs, by addressing the key barriers identified.
Data is available from the corresponding author upon reasonable request.
The authors declare that they have no conflicts of interest.
We gratefully acknowledge Dr. Gabriela Ghisi for sharing her expertise regarding best practices in translation and cross-cultural adaptation of scales. We also appreciate the contribution of 11 public hospitals in Shanghai for patient recruitment.
Supplementary Table 1: Pearson’s correlation coefficient showing association between with individual CRBS item scores with CRIAQ total scores. Supplemental Appendix: the CRBS scale