The validity of the Physical Literacy in Children Questionnaire in children aged 4 to 12

BACKGROUND

Given the growing evidence on the health benefits associated with physical literacy (PL), it is necessary to develop sound measures to assess the levels of PL in children. The Physical Literacy in Children Questionnaire (PL-C Quest) is the first self-report pictorial-based scale to assess children's perceived PL. It has good validity and reliability in Australian children aged 7 to 12 years, but little is known in younger children and in other cultural contexts. The aim of this study was to examine the validity and reliability in an expanded age range.

METHODS

A total of 1,870 Chinese children (girls, n = 871; 46.6%), aged 4 to 12 years (M = 8.07 ± 2.42) participated in validity testing. Structural equation modeling with the Weighted Least Squares with Mean and Variance approach was used to assess construct validity. The hypothesized theoretical model used the 30 items and four hypothesized factors: physical, psychological, social and cognitive capabilities. Multigroup confirmatory factor analysis was used to assess sex and age group (4-6 years, 7-9 years and 10-12 years) measurement invariance. Internal consistency analyses were conducted using polychoric alpha. A random subsample (n = 262) was selected to determine test-retest reliability using Intra-Class Correlations (ICC).

RESULTS

All items except one (moving with equipment-skateboarding) loaded on sub-domains with λ > 0.45. The hypothesized model had a good fit (CFI = 0.954, TLI = 0.950, RMSEA = 0.042), with measurement equivalence across sex and age groups separately. Internal consistency values were good to excellent (overall: α = 0.94; physical: α = 0.86; psychological: α = 0.83; social: α = 0.81; cognitive: α = 0.86). Test-retest reliability was adequate to excellent (overall: ICC = 0.90, physical: ICC = 0.86, psychological: ICC = 0.75, social: ICC = 0.71, cognitive: ICC = 0.72).

CONCLUSION

The Chinese version of the PL-C Quest is valid and reliable for testing the self-reported PL of Chinese children aged 4 to 12. This study provides the first evidence of validity for this tool in children aged 4-6 years and also evidence that the PL-C Quest would be a meaningful instrument to assess PL in Chinese children.

Measurement equivalence of the English and French versions of the self-efficacy to manage chronic disease scale: a Scleroderma Patient-Centered Intervention Network (SPIN) study

PURPOSE

The Self-Efficacy to Manage Chronic Disease (SEMCD) scale is widely used, including in systemic sclerosis (SSc). The SEMCD has been validated in SSc, but the metric equivalence of the English and French versions has not been assessed (i.e., whether psychometric properties are equivalent across English and French).

METHODS

Participants were adults from the Scleroderma Patient-Centered Intervention Network (SPIN) Cohort (N = 2159) who completed baseline measures in English (n = 1473) or French (n = 686) between May 2014 to July 2020. Analyses assessed internal consistency reliability via Cronbach's alpha and McDonald's omega, convergent validity via Pearson's correlations, structural validity via confirmatory factor analysis (CFA), and differential item functioning via the Multiple-Indicator Multiple-Cause (MIMIC) model.

RESULTS

Internal consistency reliability was high in English (α = .93, ω = .93) and French (α = .92, ω = .93). All correlations between the SEMCD and measures of health outcomes were moderate to large, statistically significant, and in the hypothesized direction in both languages. The CFA demonstrated that the one-factor model of self-efficacy, overall, fit reasonably well (CFI = .96, TLI = .93, SRMR = .03, RMSEA = .14). Standardized factor loadings were large (.76 to .88). Three items displayed statistically significant uniform DIF and all six displayed nonuniform DIF; all DIF was of minimal magnitude. Comparison of unadjusted and DIF-adjusted models indicated that DIF did not meaningfully impact total score (ICC = 0.999, r = 0.999).

CONCLUSION

Scores from English- and French-speaking adults with SSc can be combined for analysis or compared.

Measurement of psychological inflexibility: an examination of the psychometric properties of the AAQ-3 compared to AAQ-II

Due to the limitations of the existing measurements of experiential avoidance, we would like to check the validity of the improved version of Acceptance and Action Questionnaire-II (AAQ-II), i.e., Acceptance and Action Questionnaire-3 (AAQ-3), in Chinese content. The present study was aim to examine the construct and validity of the Chinese version of AAQ-3 in college students and provide an initial validation of this instrument to promote future cross-cultural examination of the psychological flexibility. Totally 1,572 college students were invited to complete the Chinese AAQ-3 and the related questionnaires at the same time. After one month, 380 participates were assessed with same questionnaires to examine the test-retest reliability. The results indicated a similar one-factor solution in the Chinese AAQ-3 to the original version by exploratory factor analysis, parallel analysis and confirmatory factor analysis. Internal consistency and test-retest reliability were good. According to the testing of the measurement invariance, the one-factor model was acceptable across gender (Man = 875, Girl = 697). Additionally, Chinese AAQ-3 was significantly negatively correlated with positive mental health (life satisfaction, mindful attention awareness), significantly positively correlated with negative emotions (depression, anxiety, stress), and significantly positively correlated with AAQ-II and Brief Experiential Avoidance Questionnaire (BEAQ). Besides, Chinese AAQ-3 was the strongest predictor of depression, anxiety, stress and life satisfaction compared to the AAQ-II and BEAQ. However, according to the exploratory structural equation model, the Chinese AAQ-3 demonstrated excellent discriminate validity from negative emotions. Overall, the AAQ-3 modified the limitations of the existing measurements of experiential avoidance (i.e., AAQ-II and BEAQ) as it showed better convergent validity with positive mental health indicators, better discriminant validity with negative emotions, and higher incremental validity. Therefore, the Chinese AAQ-3 is a valid measurement tool for assessing the level of experiential avoidance or psychological flexibility in Chinese college students.

Measurement Comparability of Electronic and Paper Administration of Visual Analogue Scales: A Review of Published Studies

BACKGROUND

Visual analogue scales (VASs) are used in a variety of patient-, observer- and clinician-reported outcome measures. While typically included in measures originally developed for pen-and-paper completion, a greater number of clinical trials currently use electronic approaches to their collection. This leads researchers to question whether the measurement properties of the scale have been conserved during the migration to an electronic format, particularly because electronic formats often use a different scale length than the 100 mm paper standard.

METHODS

We performed a review of published studies investigating the measurement comparability of paper and electronic formats of the VAS.

RESULTS

Our literature search yielded 26 studies published between 1997 and 2018 that reported comparison of paper and electronic formats using the VAS. After excluding 2 publications, 23 of the remaining 24 studies included in this review reported electronic formats of the VAS (eVAS) and paper formats (pVAS) to be equivalent. A further study concluded that eVAS and pVAS were both acceptable but should not be interchanged. eVAS length varied from 21 to 200 mm, indicating that 100 mm length is not a requirement.

CONCLUSIONS

The literature supports the hypothesis that eVAS and pVAS provide comparable results regardless of the VAS length. When implementing a VAS on a screen-based electronic mode, we recommend following industry best practices for faithful migration to minimise the likelihood of non-comparability with pVAS.

Stronger feelings of loneliness among Moroccan and Turkish older adults in the Netherlands: in search for an explanation

The prevalence of loneliness among Turkish-Dutch and Moroccan-Dutch older adults is higher than among Dutch older adults of non-migrant origin. Three explanations may account for this difference: (1) differential item functioning might result in scores that vary in intensity and in meaning across categories; (2) the position of migrants is much more vulnerable than that of non-migrants; (3) the lack of protective factors has more severe consequences for older migrants. The Longitudinal Aging Study Amsterdam interviewed 176 persons born in Morocco and 235 born in Turkey, aged 55-66 and living in urban areas. They are compared with a matched sample of 292 Dutch persons. The psychometric properties of the loneliness scale are satisfying, although there is some differential item functioning. Older migrants have more frequent social contacts but are at a disadvantage in other domains. Taking into account differences in social participation, satisfaction with income, mastery and depressive symptoms, the difference between older migrants' and non-migrants' loneliness is reduced by more than half. Protective factors are equally important for older migrants and non-migrants. Exceptions are marriage (less protective for Moroccans), frequent contact with children/children-in-law (mostly for Turks), a higher educational level (protects Moroccans and Turks) and better physical functioning (less for Turks). Being an older migrant and belonging to a minority might further contribute to feelings of loneliness. Interventions can be directed at stimulating social contact, but also at aspects like enhancing the appreciation of their social status and avoiding negative interpretations of a situation.

Care Recipient Controlling and Manipulative Behavior and Caregiver Depressive Symptoms: The Role of Race, Caregiver Resentment, and Mutual Communal Behavior

BACKGROUND AND OBJECTIVES

We explored whether relationship quality, as measured by mutual communal behavior, would serve as a buffer against caregiver resentment and, consequently, depressive symptoms when care recipients (CRs) engage in problem behavior (i.e., controlling and manipulative behavior [CMB]). Using the common core model of caregiver distress, we hypothesized that caregiver resentment would explain why caregivers were depressed when their CRs engage in CMB. We predicted that the indirect effect of CRCMB on depressive symptoms via resentment would depend on the strength of the communal bond between the caregiver and CR. Resentment was expected to play a significant role in explaining the association between CRCMB and depressive symptoms for caregivers in less communal relationships, but a small or nonexistent role for those in highly communal relationships. We also investigated whether these effects were different for Black and White caregivers.

RESEARCH DESIGN AND METHODS

Data were obtained from 187 Black and 247 White caregivers from the second Family Relationships in Late Life Project. Before testing our model, we confirmed the measurement equivalence/invariance of the four scales used in this study.

RESULTS

Resentment mediated the association between CRCMB and depressive symptoms. However, the indirect effect was larger among highly communal caregivers. Caregiver race did not moderate the moderated mediation.

DISCUSSION AND IMPLICATIONS

The communal bond between the caregiver and CR does not entirely protect the caregiver from depressive symptoms, particularly among highly communal caregivers. Interventions aimed at improving caregiver outcomes should acknowledge the unique vulnerabilities of caregivers in close relationships.

Examining the measurement equivalence of the Maslach Burnout Inventory across age, gender, and specialty groups in US physicians

Background

Disparities in US physician burnout rates across age, gender, and specialty groups as measured by the Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI) are well documented. We evaluated whether disparities in US physician burnout are explained by differences in the MBI’s functioning across physician age, gender, and specialty groups.

Methods

We assessed the measurement equivalence of the MBI across age, gender, and specialty groups in multi-group item response theory- (IRT-) based differential item functioning (DIF) analyses using secondary, cross-sectional survey data from US physicians (n = 6577). We detected DIF using two IRT-based methods and assessed its impact by estimating the overall average difference in groups’ subscale scores attributable to DIF. We assessed DIF’s practical significance by comparing differences in individuals’ subscale scores and burnout prevalence estimates from models unadjusted and adjusted for DIF.

Results

We detected statistically significant age-, gender-, and specialty- DIF in all but one MBI item. However, in all cases, average differences in expected subscale-level scores due to DIF were < 0.10 SD on each subscale. Differences in physicians’ individual-level subscale scores and burnout symptom prevalence estimates across DIF- adjusted and unadjusted IRT models were also small (in all cases, mean absolute differences in individual subscale scores were < 0.04 z-score units; prevalence estimates differed by < 0.70%).

Conclusions

Age-, gender-, and specialty-related disparities in US physician burnout are not explained by differences in the MBI’s functioning across these demographic groups. Our findings support the use of the MBI as a valid tool to assess age-, gender-, and specialty-related disparities in US physician burnout.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-021-00312-2.

The EQ-5D-3L administered by text message compared to the paper version for hard-to-reach populations in a rural South African trauma setting: a measurement equivalence study

INTRODUCTION

Administering patient-reported outcome measures (PROMs) by text message may improve response rate in hard-to-reach populations. This study explored cultural acceptability of PROMs and compared measurement equivalence of the EQ-5D-3L administered on paper and by text message in a rural South African setting.

MATERIALS AND METHODS

Participants with upper or lower limb orthopaedic pathology were recruited. The EQ-5D was administered first on paper and then by text message after 24 h and 7 days. Differences in mean scores for paper and text message versions of the EQ-5D were evaluated. Test-retest reliability between text message versions was evaluated using Intraclass Correlation Coefficients (ICCs).

RESULTS

147 participants completed a paper EQ-5D. Response rates were 67% at 24 h and 58% at 7 days. There were no differences in means between paper and text message responses for the EQ-5D Index (p = 0.95) or EQ-5D VAS (p = 0.26). There was acceptable agreement between the paper and 24-h text message EQ-5D Index (0.84; 95% Confidence Interval (CI) 0.78-0.89) and EQ-5D VAS (0.73; 95% CI 0.64-0.82) and acceptable agreement between the 24-h and 7-day text message EQ-Index (0.72; CI 0.62-0.82) and EQ-VAS (0.72; CI 0.62-0.82). Non-responder traits were increasing age, Xhosa as first language and lower educational levels.

CONCLUSIONS

Text messaging is equivalent to paper-based measurement of EQ-5D in this setting and is thus a viable tool for responders. Non-responders had similar socioeconomic characteristics and attrition rates to traditional modes of administration. The EQ-5D by text message offers potential clinical and research uses in hard-to-reach populations.

The Comparability of Perceived Physical and Mental Health Measures Across Immigrants and Natives in the United States

The comparative study of perceived physical and mental health in general-and the comparative study of health between the native-born and immigrants, in particular-requires that the groups understand survey questions inquiring about their health in the same way and display similar response patterns. After all, observed differences in perceived health may not reflect true differences but rather cultural bias in the health measures. Research on cross-country measurement equivalence between immigrants and natives on self-reported health measures has received very limited attention to date, resulting in a growing demand for the validation of existing perceived health measures using samples of natives and immigrants and establishing measurement equivalence of health-related assessment tools. This study, therefore, aims to examine measurement equivalence of self-reported physical and mental health indicators between immigrants and natives in the United States. Using pooled data from the 2015-2017 IPUMS Health Surveys, we examine the cross-group measurement equivalence properties of five concepts that are measured by multiple indicators: (1) perceived limitations in activities of daily life; (2) self-reported disability; (3) perceived functional limitations; (4) perceived financial stress; and (5) nonspecific psychological distress. Furthermore, we examine the comparability of these data among respondents of different ethnoracial origins and from different regions of birth, who report few versus many years since migration, their age, gender, and the language used to respond to the interview (e.g., English vs. Spanish). We test for measurement equivalence using multigroup confirmatory factor analysis. The results reveal that health scales are comparable across the examined groups. This finding allows drawing meaningful conclusions about similarities and differences among natives and immigrants on measures of perceived health in these data.

Does scrolling affect measurement equivalence of electronic patient-reported outcome measures (ePROM)? Results of a quantitative equivalence study

BACKGROUND

Scrolling is a perceived barrier in the use of bring your own device (BYOD) to capture electronic patient reported outcomes (ePROs). This study explored the impact of scrolling on the measurement equivalence of electronic patient-reported outcome measures (ePROMs) in the presence and absence of scrolling.

METHODS

Adult participants with a chronic condition involving daily pain completed ePROMs on four devices with different scrolling properties: a large provisioned device not requiring scrolling; two provisioned devices requiring scrolling - one with a "smart-scrolling" feature that disabled the "next" button until all information was viewed, and a second without this feature; and BYOD with smart-scrolling. The ePROMs included were the SF-12, EQ-5D-5L, and three pain measures: a visual analogue scale, a numeric response scale and a Likert scale. Participants completed English or Spanish versions according to their first language. Associations between ePROM scores were assessed using intraclass correlation coefficients (ICCs), with lower bound of 95% confidence interval (CI) > 0.7 indicating comparability.

RESULTS

One hundred fifteen English- or Spanish-speaking participants (21-75y) completed all four administrations. High associations between scrolling and non-scrolling were observed (ICCs: 0.71-0.96). The equivalence threshold was met for all but one SF-12 domain score (bodily pain; lower 95% CI: 0.65) and two EQ-5D-5L item scores (pain/discomfort, usual activities; lower 95% CI: 0.64/0.67). Age, language, and device size produced insignificant differences in scores.

CONCLUSIONS

The measurement properties of PROMs are preserved even in the presence of scrolling on a handheld device. Further studies that assess scrolling impact over long-term, repeated use are recommended.

Measurement Equivalence of the Subjective Well-Being Scale Among Racially/Ethnically Diverse Older Adults

OBJECTIVES

The present study examined differences by race/ethnicity in the measurement equivalence of the Subjective Well-Being Scale (SWBS) among older adults in the United States.

METHOD

Drawn from the National Health and Aging Trends Study (NHATS), adults aged 65 years and older from three racial/ethnic groups (n = 1,200) were selected for the analyses from a total of 8,245: 400 non-Hispanic Whites, 400 African Americans, and 400 Hispanics/Latinos. We tested measurement equivalence of the SWBS that is categorized into three domains: positive and negative affect (four items), self-realization (four items), and self-efficacy and resilience (three items). Multiple-group confirmatory factor analyses were conducted to test measurement invariance.

RESULTS

After adjusting for age, gender, and education, the underlying construct of the SWBS was noninvariant across three racial/ethnic elderly groups.

DISCUSSION

Findings suggest that the comparison of latent means (especially for positive and negative affect and self-realization) across racial/ethnic groups is highly questionable. The SWBS should be used with extreme caution when it is applied to diverse racial/ethnic elderly groups for comparison purposes. Implications are discussed in cultural and methodological contexts.

Differential item functioning of the CAHPS® In-Center Hemodialysis Survey

PURPOSE

End-stage renal disease patients' experience of care is an integral part of the assessment of the quality of the care provided at hemodialysis centers and is needed to promote patient choice, quality improvement, and accountability. The purpose of this study is to evaluate the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS®) survey and its equivalence in different age, gender, race, and education subgroups.

METHODS

The ICH-CAHPS survey was administered to 1454 patients from 32 dialysis facilities. For the characteristics compared, the sample had 756 participants younger than 65 years old, 739 men, 516 Black, 567 White, and 970 with less than high school diploma. Three different patient experience constructs were studied including nephrologist's communication and caring, quality of care and operations, and providing information to patients. We used item response theory analysis to examine the possibility of differential item functioning (DIF) by patient age, gender, race, and education separately after controlling for the other DIF characteristics and additional confounding variables including survey mode, mental, and general health status as well as duration on dialysis.

RESULTS

The three constructs studied were unidimensional and no major DIF was observed on the composites. Some non-equivalences were observed when confounders were not controlled for, suggesting that such covariates can be important factors in understanding the possibility of disparity in patients' experience.

CONCLUSIONS

The ICH-CAHPS is a promising survey to elicit hemodialysis patients' experience that has good psychometric properties and provides a standardized tool for assessing age, gender, race, or education disparity.

The measurement invariance of the Patient Health Questionnaire-9 for American Indian adults

BACKGROUND

American Indian people have high suicide rates. However, little epidemiological data is available on depression prevalence, a suicide risk factor, in this population. Some research suggests that depression scales may perform differently for American Indian people. However, the Patient Health Questionnnaire-9 (PHQ-9), a depression scale widely-used in clinical practice, had not been assessed for cross-cultural measurement invariance with American Indian people.

METHODS

In this retrospective study of existing electronic health record (EHR) data in an upper Midwestern healthcare system, we assessed the measurement invariance of the standard one-factor PHQ-9 and five previously identified two-factor models for 4443 American Indian and 4443 Caucasian American adults (age >= 18) with a PHQ-9 in the EHR from 12/1/2005 to 12/31/2017. We also conducted subgroup analyses with adults ages >= 65.

RESULTS

Models showed good fits (e.g., CFI > 0.99, RMSEA < 0.05) and internal consistency reliability (ordinal alpha > 0.80). All models displayed measurement invariance between racial groups. Factor correlation was high for two-factor models, providing support for the one-factor model. American Indian adults had significantly higher odds of PHQ-9 total scores >= 10 and >= 15 than Caucasian American adults.

LIMITATIONS

Data came from a single healthcare system.

CONCLUSIONS

The PHQ-9 exhibited cross-cultural measurement invariance between American Indian and Caucasian American adults, supporting the PHQ-9 as a depression screening tool in this clinical care population. American Indian adults also had higher levels of depression than Caucasian Americans. Future research could confirm the generalizability of our findings to other American Indian populations.

Psychometric properties of the Chinese version of the Childhood Trauma Questionnaire-Short Form (CTQ-SF) among undergraduates and depressive patients

OBJECTIVE

The Childhood Trauma Questionnaire-Short Form (CTQ-SF) is a self-report questionnaire that retrospectively provides screening for a history of childhood abuse and neglect, and which is widely used throughout the world. The current study aimed to examine the psychometric properties of the Chinese version of the CTQ-SF.

METHODS

Participants included 3431 undergraduates from Hunan provinces and 234 depressive patients from psychological clinics. Confirmatory factor analysis was performed to examine how well the original five-factor model fit the data and the measurement equivalence of CTQ-SF across gender. Internal consistency was also evaluated.

RESULTS

The five-factor model achieved satisfactory fit (Undergraduate sample TLI = 0.925, CFI = 0.936, RMSEA = 0.034, SRMR = 0.046; depressive sample TLI = 0.912, CFI = 0.923, RMSEA = 0.044, SRMR = 0.062). Measurement invariance of the five-factor model across gender was supported fully assuming different degrees of invariance. The CTQ-SF also showed acceptable internal consistency and good stability.

CONCLUSION

The current study provides that the Chinese version of the Childhood Trauma questionnaire-short form has good reliability and validity among Chinese undergraduates and depressive samples, which also indicates that the CTQ-SF is a good tool for child trauma assessment.

Measurement equivalence of the Social Interaction Anxiety Scale (SIAS) and Social Phobia Scale (SPS) across individuals with social anxiety disorder from Japanese and Australian sociocultural contexts

BACKGROUND

Cultural factors influence both the expression of social anxiety and the interpretation and functioning of social anxiety measures. This study aimed to test the measurement equivalence of two commonly used social anxiety measures across two sociocultural contexts using individuals with social anxiety disorder (SAD) from Australia and Japan.

METHODS

Scores on the straightforwardly-worded Social Interaction Anxiety Scale (S-SIAS) and the Social Phobia Scale (SPS) from two archival datasets of individual with SAD, one from Australia (n = 201) and one from Japan (n = 295), were analysed for measurement equivalence using a multigroup confirmatory factor analysis (CFA) framework.

RESULTS

The best-fitting factor models for the S-SIAS and SPS were not found to be measurement equivalent across the Australian and Japanese samples. Instead, only a subset of items was invariant. When this subset of invariant items was used to compare social anxiety symptoms across the Australian and Japanese samples, Japanese participants reported lower levels of fear of attracting attention, and similar levels of fear of overt evaluation, and social interaction anxiety, relative to Australian participants.

LIMITATIONS

We only analysed the measurement equivalence of two social anxiety measures using a specific operationalisation of culture. Future studies will need to examine the measurement equivalence of other measures of social anxiety across other operationalisations of culture.

CONCLUSIONS

When comparing social anxiety symptoms across Australian and Japanese cultures, only scores from measurement equivalent items of social anxiety measures should be used. Our study highlights the importance of culturally-informed assessment in SAD.

Measurement equivalence of the short-form Quality of Life in Childhood Epilepsy Questionnaire (QOLCE-16)

OBJECTIVE

The aim of this study was to assess measurement equivalence in the 16-item short-form Quality of Life in Childhood Epilepsy Questionnaire (QOLCE-16) across age, sex, and time in a sample of children with newly diagnosed epilepsy.

METHODS

Data came from 373 children participating in the Health-related Quality of Life in Children with Epilepsy Study (HERQULES), a multicenter prospective cohort study. Measurement equivalence was assessed using multigroup confirmatory factor analysis methods. Comparison groups were stratified by age (4-7 years vs. 8-12 years), sex (male vs. female), and time (at diagnosis vs. 24 months postdiagnosis).

RESULTS

The QOLCE-16 demonstrated measurement equivalence at the level of strict invariance for each comparison group tested - age: χ² (3, 274) = 429.6, p < 0.001; comparative fit index (CFI) = 0.985; root mean square error of approximation (RMSEA) = 0.056 (0.046, 0.066); sex: χ² (3, 271) = 430.5, p < 0.001; CFI = 0.984; RMSEA = 0.057 (0.047, 0.067); and time: χ² (3, 269) = 566.4, p < 0.001; CFI = 0.985; RMSEA = 0.059 (0.052, 0.066).

SIGNIFICANCE

The findings provide support for the robust psychometric profile of the QOLCE-16 as a reliable and valid measure of health-related quality of life for children with epilepsy. Demonstrating good properties and a multidimensional structure, the QOLCE-16 is an appropriate short measure for both clinicians and researchers wanting to obtain health-related quality of life information on children with epilepsy.

Cross-cultural validation of the German version of the Four-Dimensional Symptom Questionnaire (4DSQ) in multimorbid elderly people

PURPOSE

Psychosomatic symptoms and mental health problems are highly prevalent in multimorbid elderly people challenging general practitioners to differentiate between normal stress and psychopathological conditions. The 4DSQ is a Dutch questionnaire developed to detect anxiety, depression, somatization, and distress in primary care. This study aims to analyze measurement equivalence between a German version and the original Dutch instrument.

METHODS

A Dutch and a German sample of multimorbid elderly people, matched by gender and age, were analyzed. Equivalence of scale structures was assessed by confirmatory factor analysis (CFA). To evaluate measurement equivalence across languages, differential item functioning (DIF) was analyzed using Mantel-Haenszel method and hybrid ordinal logistic regression analysis. Differential test functioning (DTF) was assessed using Rasch analysis.

RESULTS

A total of 185 German and 185 Dutch participants completed the questionnaire. The CFA confirmed one-factor models for all scales of both 4DSQ versions. Nine items in three scales were flagged with DIF. The anxiety scale showed to be free of DIF. DTF analysis revealed negligible scale impact of DIF.

CONCLUSIONS

The German 4DSQ demonstrated measurement equivalence to the original Dutch instrument. Hence, it can be considered a valid questionnaire for the screening for mental health problems in primary care.

The assessment of bystander intervention in bullying: Examining measurement invariance across gender

Research on bystander intervention in bullying has indicated that prosocial helping behavior is not consistent across gender, with girls engaging in more bystander intervention; however, a search of the literature does not reveal any studies that have examined the validity of bystander intervention measurement across subpopulations. The purpose of the current study was to investigate measurement invariance across gender in both the elementary and middle school versions of the Bystander Intervention Model in Bullying measure among a sample of 682 fourth to eighth grade students (46% girls, 47% low income, 87% White). Results suggest evidence of measurement equivalence of the five-step bystander intervention model across gender in the elementary and middle school samples. Given this, there is evidence that the measure can be used for research and practical purposes in these grade levels and that comparisons between boys and girls are appropriate.

Detecting pre-death grief in family caregivers of persons with dementia: measurement equivalence of the Mandarin-Chinese version of Marwit-Meuser caregiver grief inventory

Background

Pre-death grief (PDG) is a key challenge faced by caregivers of persons with dementia (PWD). Marwit-Meuser Caregiver Grief Inventory (MM-CGI) and its abbreviated MM-CGI-Short-Form (MM-CGI-SF) are among the few empirically-developed scales that detect PDG. However, they have not had a Mandarin-Chinese version even though Chinese-speaking populations have among the largest number of PWD. We produced a Mandarin-Chinese version of MM-CGI and evaluated whether it had equivalent scores and similar psychometric properties to the English version.

Methods

We produced the Chinese MM-CGI through the methods of forward-backward translation and cognitive debriefing. Then, we recruited family caregivers of PWD (n = 394) to complete either the Chinese (n = 103) or English (n = 291) version. The two versions were compared in their score-difference (adjusting for potential confounders using multiple linear regression), internal-consistency reliability (using Cronbach’s α) and test-retest reliability (using intraclass correlation-coefficient), known-group validity (based on the relationship with the PWD and stage of dementia) and construct validity (using Spearman’s correlation-coefficient).

Results

The two versions showed similar mean scores, with the adjusted score-difference of 1.2 (90% CI -5.6 to 7.9) for MM-CGI and − 0.4 (90% CI -2.9 to 2.1) for MM-CGI-SF. The 90% CI for adjusted score-difference fell within predefined equivalence-margin (±8 for MM-CGI and ± 3 for MM-CGI-SF) and indicated equivalence of the scores. The two versions also demonstrated similar characteristics in reliability and validity.

Conclusions

The Chinese MM-CGI opens the way for PDG assessment and intervention among Chinese-speaking caregivers. Establishing its measurement equivalence with the English version paves the way for cross-cultural research on PDG in dementia caregiving.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0804-5) contains supplementary material, which is available to authorized users.

Assessing the equivalence of Web-based and paper-and-pencil questionnaires using differential item and test functioning (DIF and DTF) analysis: a case of the Four-Dimensional Symptom Questionnaire (4DSQ)

PURPOSE

Many paper-and-pencil (P&P) questionnaires have been migrated to electronic platforms. Differential item and test functioning (DIF and DTF) analysis constitutes a superior research design to assess measurement equivalence across modes of administration. The purpose of this study was to demonstrate an item response theory (IRT)-based DIF and DTF analysis to assess the measurement equivalence of a Web-based version and the original P&P format of the Four-Dimensional Symptom Questionnaire (4DSQ), measuring distress, depression, anxiety, and somatization.

METHODS

The P&P group (n = 2031) and the Web group (n = 958) consisted of primary care psychology clients. Unidimensionality and local independence of the 4DSQ scales were examined using IRT and Yen's Q3. Bifactor modeling was used to assess the scales' essential unidimensionality. Measurement equivalence was assessed using IRT-based DIF analysis using a 3-stage approach: linking on the latent mean and variance, selection of anchor items, and DIF testing using the Wald test. DTF was evaluated by comparing expected scale scores as a function of the latent trait.

RESULTS

The 4DSQ scales proved to be essentially unidimensional in both modalities. Five items, belonging to the distress and somatization scales, displayed small amounts of DIF. DTF analysis revealed that the impact of DIF on the scale level was negligible.

CONCLUSIONS

IRT-based DIF and DTF analysis is demonstrated as a way to assess the equivalence of Web-based and P&P questionnaire modalities. Data obtained with the Web-based 4DSQ are equivalent to data obtained with the P&P version.

Structural stability, quantitative change: A latent class analysis approach towards gender role attitudes in Germany

Since the 1960s, social science surveys have aimed to assess respondents' attitudes towards gender roles. In this paper, a model-based clustering approach towards gender role attitudes is proposed in contrast to commonly used dimensional methods. Working from a role theory perspective, we expect different profiles in the population when it comes to role expectations. Using data from the German General Social Survey in 1991 and 2012, we identify attitude patterns via multi-group latent class analysis, taking differences between Eastern and Western Germany into account. Five latent classes representing different combinations of role expectations towards couples and parents and varying levels of intensity are distinguished. Attitude change is assessed by comparing latent class prevalence over time, while statistically testing for measurement equivalence. The analysis reveals a regionally variable decrease in traditional role models: Eastern Germany exhibits a faster pace of 'de-traditionalization' and less potential for role conflicts regarding working mothers.

Does company size matter? Validation of an integrative model of safety behavior across small and large construction companies

INTRODUCTION

Previous safety climate studies primarily focused on either large construction companies or the construction industry as a whole, while little is known about whether company size has significant effects on workers' understanding of safety climate measures and relationships between safety climate factors and safety behavior. Thus, this study aims to: (a) test the measurement equivalence (ME) of a safety climate measure across workers from small and large companies; (b) investigate if company size alters the causal structure of the integrative model developed by Guo, Yiu, and González (2016).

METHOD

Data were collected from 253 construction workers in New Zealand using a safety climate measure. This study used multi-group confirmatory factor analyses (MCFA) to test the measurement equivalence of the safety climate measure and structure invariance of the integrative model.

RESULTS

Results indicate that workers from small and large companies understood the safety climate measure in a similar manner. In addition, it was suggested that company size does not change the causal structure and mediational processes of the integrative model.

CONCLUSIONS

Both measurement equivalence of the safety climate measure and structural invariance of the integrative model were supported by this study. Practical applications: Findings of this study provided strong support for a meaningful use of the safety climate measure across construction companies in different sizes. Safety behavior promotion strategies designed based on the integrative model may be well suited for both large and small companies.

Examining gender-related differential item functioning of the Veterans Rand 12-item Health Survey

PURPOSE

Previous research suggests that gender differences in patient-reported outcome measures (PROMs) may reflect measurement bias rather than true differences in underlying health status. The aim of this study is to examine whether the Veterans Rand 12-item Health Survey (VR-12) allows for unbiased comparisons of physical and mental health scores across gender. The VR-12 is a generic PROM consisting of 12 items with 3-6 response options for the measurement of mental and physical health.

METHODS

Study data were from the 2015 Health Outcomes Survey pertaining to the Medicare beneficiaries. A total of 277,518 participants included 116,817 (42.1%) males and 160,701 (57.9%) females. Scale-level and item-level differential functioning methods were applied using multiple-group confirmatory factor analysis and ordinal logistic regression, respectively.

RESULTS

The scale-level differential functioning showed support for strict invariance (RMSEA = 0.045; CFI = 0.995) across gender. Although we found statistically significant differential item functioning for several items, the magnitude was negligible (maximum ΔR ² = 0.007).

CONCLUSION

The VR-12 physical and mental health status scores are unbiased with respect to gender.

Psychometric properties of the 10-item ruminative response scale in Chinese university students

BACKGROUND

Rumination increases vulnerability to depression, exacerbates and perpetuates negative moods. This study was aimed to examine the psychometric properties of the Chinese version of the 10-item Ruminative Response Scale (RRS-10) in a large undergraduate sample.

METHODS

A sample of 5,236 university students finished the RRS and the Center for Epidemiological Studies Depression Scale (CES-D). Confirmatory Factor Analysis (CFA) was performed to examine the two-factor structure and the measurement equivalence of the RRS-10 across gender. The internal consistency, test-retest reliability, correlations among RRS, RRS-10 and CES-D were also explored. In addition, gender difference on rumination and the relationship between rumination and depression were further investigated.

RESULTS

The two-factor model of RRS-10 fit the data reasonably and had acceptable internal consistency and test-retest reliability in Chinese undergraduates sample. And the measurement equivalence of the RRS-10 was acceptable across gender in Chinese university students. Findings in respect of latent means and manifest means revealed non-significant gender difference in RRS-10. Besides, participants with high-level rumination had more depressive symptoms than those with low-level rumination.

CONCLUSIONS

The Chinese version of the RRS-10 showed good psychometric properties and was measurement invariant across gender in undergraduates.

Validating the shortened Quality of Life in Childhood Epilepsy Questionnaire (QOLCE-55) in a sample of children with drug-resistant epilepsy

OBJECTIVE

The aim of this study was to validate the newly developed shortened Quality of Life in Childhood Epilepsy Questionnaire (QOLCE-55) in a sample of children with drug-resistant epilepsy.

METHODS

Data came from 136 children enrolled in the Impact of Pediatric Epilepsy Surgery on Health-Related Quality of Life Study (PEPSQOL), a multicenter prospective cohort study. Confirmatory factor analysis was used to assess the higher-order factor structure of the QOLCE-55. Convergent and divergent validity was assessed by correlating subscales of the KIDSCREEN-27 with the QOLCE-55. Measurement equivalence of the QOLCE-55 was evaluated using multiple-group confirmatory factor analysis of children with drug-resistant epilepsy from PEPSQOL versus children with new-onset epilepsy from HERQULES (Health-Related Quality of Life in Children with Epilepsy Study).

RESULTS

The higher-order factor structure of the QOLCE-55 demonstrated adequate fit: Comparative Fit Index (CFI) = 0.948; Tucker-Lewis Index (TLI) = 0.946; Root Mean Square of Approximation (RMSEA) = 0.060 (90% confidence interval [CI] 0.054-0.065); Weighted Root Mean Square Residuals (WRMR) = 1.247. Higher-order factor loadings were strong, ranging from λ = 0.74 to 0.81. Internal consistency reliability was excellent (α = 0.97, subscales α > 0.82). QOLCE-55 subscales demonstrated moderate to strong correlations with similar subscales of the KIDSCREEN-27 (ρ = 0.43-0.75) and weak to moderate correlations with dissimilar subscales (ρ = 0.25-0.42). The QOLCE-55 demonstrated partial measurement equivalence at the level of strict invariance - χ² (2,823) = 3,727.9, CFI = 0.961, TLI = 0.962, RMSEA = 0.049 (0.044, 0.053), WRMR = 1.834.

SIGNIFICANCE

The findings provide support for the factor structure of the QOLCE-55 and contribute to its robust psychometric profile as a reliable and valid measure. Researchers and health practitioners should consider the QOLCE-55 as a viable option for reducing respondent burden when assessing health-related quality of life in children with epilepsy.

Measurement and structural invariance of the US version of the Birth Satisfaction Scale-Revised (BSS-R) in a large sample

BACKGROUND

The 10-item Birth Satisfaction Scale-Revised (BSS-R) is being increasingly used internationally. The use of the measure and the concept has gathered traction in the United States following the development of a US version of the tool. A limitation of previous studies of the measurement characteristics of the BSS-R is modest sample size. Unplanned pregnancy is recognised as being associated with a range of negative birth outcomes, but the relationship to birth satisfaction has received little attention, despite the importance of birth satisfaction to a range of postnatal outcomes.

AIM

The current investigation sought to evaluate the measurement characteristics of the BSS-R in a large postpartum sample.

METHODS

Multiple Groups Confirmatory Factor Analysis (MGCFA) was used to evaluate a series of measurement and structural models of the BSS-R to evaluate fundamental invariance characteristics using planned/unplanned pregnancy status to differentiate groups.

FINDINGS

Complete data from N=2116 women revealed that the US version of the BSS-R offers an excellent fit to data and demonstrates full measurement and structural invariance. Little difference was observed between women on the basis of planned/unplanned pregnancy stratification on measures of birth satisfaction.

DISCUSSION

The established relationship between unplanned pregnancy and negative perinatal outcomes was not found to extend to birth satisfaction in the current study. The BSS-R demonstrated exemplary measurement and structural invariance characteristics.

CONCLUSION

The current study strongly supports the use of the US version of the BSS-R to compare birth satisfaction across different groups of women with theoretical and measurement confidence.

Measurement equivalence of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Medicare survey items between Whites and Asians

PURPOSE

Asians report worse experiences with care than Whites. This could be due to true differences in care received, expectations about care, or survey response styles. We examined responses to the Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) Medicare survey items by Whites and Asians, controlling for underlying level on the CAHPS constructs.

METHODS

We conducted multiple group analyses to evaluate measurement equivalence of CAHPS Medicare survey data between White and Asian Medicare beneficiaries for CAHPS reporting composites (communication with personal doctor, access to care, plan customer service) and global ratings of care using pooled data from 2007 to 2011. Responses were obtained from 1,326,410 non-Hispanic Whites and 40,672 non-Hispanic Asians (hereafter referred to as Whites and Asians). The median age for Whites was 70, with 24 % 80 or older, and 70 for Asians, with 23 % 80 or older. Fifty-eight percent of Whites and 56 % of Asians were female.

RESULTS

A model without group-specific estimates fit the data as well as a model that included 12 group-specific estimates (7 factor loadings, 3 measured variable errors, and 2 item intercepts): Comparative Fit Index = 0.947 and 0.948; root-mean-square error of approximation = 0.052 and 0.052, respectively). Differences in latent CAHPS score means between Whites and Hispanics estimated from the two models were similar, differing by 0.053 SD or less.

CONCLUSIONS

This study provides support for measurement equivalence of the CAHPS Medicare survey composites (communication, access, customer service) and global ratings between White and Asian respondents, supporting comparisons of care experiences between the two groups.

Can We Trust Measures of Political Trust? Assessing Measurement Equivalence in Diverse Regime Types

Do standard "trust in government" survey questions deliver measures which are reliable and equivalent in meaning across diverse regime types? I test for the measurement equivalence of political trust in a sample of 35 former Soviet and European countries using the 2010 Life in Transition Survey II conducted by the World Bank and European Bank for Reconstruction and Development. Employing multiple group confirmatory factor analysis, I find that trust perceptions in central political institutions differ from (1) trust in regional and local political institutions, (2) trust in protective institutions like the armed forces and police and (3) trust in order institutions like the courts and police. Four measurement models achieve partial metric invariance and two reach partial scalar invariance in most countries, allowing for comparisons of correlates using latent factors from each model. I also found some clustering of measurement error and variation in the dimensionality of political trust between democratic and autocratic portions of the sample. On some measurement parameters, therefore, respondents in diverse cultures and regime types do not have equivalent understandings of political trust. The findings offer both optimism and a note of caution for researchers using political trust measures in cross-regime contexts.

Applying Rasch analysis to evaluate measurement equivalence of different administration formats of the Activity Limitation scale of the Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR)

BACKGROUND

Electronic formats of patient-reported outcome (PRO) measures are now routinely used in clinical research studies. When changing from a validated paper and pen to electronic administration it is necessary to establish their equivalence. This study reports on the value of Rasch analysis in this process.

METHODS

Three groups of US pulmonary hypertension (PH) patients participated. The first completed an electronic version of the CAMPHOR Activity Limitation scale (e-sample) and this was compared with two pen and paper administrated samples (pp1 and pp2). The three databases were combined and analysed for fit to the Rasch model. Equivalence was evaluated by differential item functioning (DIF) analyses.

RESULTS

The three datasets were matched randomly in terms of sample size (n = 147). Mean age (years) and percentage of male respondents were as follows: e-sample (51.7, 16.0 %); pp1 (50.0, 14.0 %); pp2 (55.5, 40.4 %). The combined dataset achieved fit to the Rasch model. Two items showed evidence of borderline DIF. Further analyses showed the inclusion of these items had little impact on Rasch estimates indicating the DIF identified was unimportant.

CONCLUSIONS

Differences between the performance of the electronic and pen and paper administrations of the CAMPHOR Activity Limitation scale were minor. The results were successful in showing how the Rasch model can be used to determine the equivalence of alternative formats of PRO measures.

The stability of elementary school contexts from kindergarten to third grade

The nature and measurement of school contexts have been the foci of interest in community, developmental, and school psychology for decades. In this paper, we tested the stability of six elementary school-context factors over time, using a nationally representative and longitudinal sample of schools from the Early Childhood Longitudinal Study, Kindergarten Class of 1998-1999 (ECLS-K), and systems theories as a conceptual framework. Confirmatory factor analyses and tests of measurement equivalence revealed that six latent factors fit the data equally well across kindergarten, first grade, and third grade: school strain, school safety practices, school academic performance, school instructional resources, positive school climate, and school violence and crime. The factors were highly stable across the early elementary school years, with standardized stability coefficients ranging from .87 to .99 between kindergarten and first grade and from .71 to .98 between the first and third grades. Equivalence in the two sets of stability coefficients was also found across time. Both the magnitude and equivalence of the stability coefficients were robust to the inclusion of five key exogenous school characteristics as covariates in the model. Results suggest that elementary school contexts are remarkably stable over time and shed light on methodological considerations regarding the treatment of school-level measures in analyses that examine links between school context and children's academic and developmental trajectories.

Interpretation and use of the 5-level EQ-5D response labels varied with survey language among Asians in Singapore

OBJECTIVES

This study aimed to investigate the comparability of the English, Chinese, and Malay versions of the 5-level EQ-5D (EQ-5D-5L) response labels in Singapore.

STUDY DESIGN AND SETTING

Visitors to a primary care institution in Singapore (n = 743) were asked to complete two exercises: (1) rating the severity of the EQ-5D-5L response labels presented in English, Chinese, or Malay using a 0-100 numeric rating scale and (2) using the labels to describe various hypothetical health problems. Label ratings and choices between language versions were compared using regression analysis.

RESULTS

Perceived severity of the English and Chinese labels was similar. Compared with their English counterparts, the Malay label "slight(ly)" was rated as more severe (adjusted mean difference: 10.5 to 14.5) and "unable"/"extreme(ly)" as less severe (adjusted mean difference: -13.3 to -11.0) (P < 0.001 for all). The Malay labels "no(t)" and "unable"/"extreme(ly)" and the less severe Chinese labels were more frequently used to describe hypothetical health problems than their English counterparts.

CONCLUSION

Interpretation and use of the EQ-5D-5L response labels vary among Singaporeans using different language versions of the instrument. Future studies need to investigate ways to reduce the variations and increase the cross-cultural measurement equivalence of the instrument.

Does safety climate predict safety performance in Italy and the USA? Cross-cultural validation of a theoretical model of safety climate

Previous studies have acknowledged the relevance of assessing the measurement equivalence of safety related measures across different groups, and demonstrating whether the existence of disparities in safety perceptions might impair direct group comparisons. The Griffin and Neal (2000) model of safety climate, and the accompanying measure (Neal et al. [NGH], 2000), are both widely cited and utilized. Yet neither the model in its entirety nor the measure have been previously validated across different national contexts. The current study is the first to examine the NGH measurement equivalence by testing whether their model of safety climate predicting safety performance is tenable in both English speaking and non-English speaking countries. The study involved 616 employees from 21 organizations in the US, and 738 employees from 20 organizations in Italy. A multi-group confirmatory factor analytic approach was used to assess the equivalence of the measures across the two countries. Similarly, the structural model of relations among the NGH variables was examined in order to demonstrate its cross-country invariance. Results substantially support strict invariance across groups for the NGH safety scales. Moreover, the invariance across countries is also demonstrated for the effects of safety climate on safety knowledge and motivation, which in turn positively relate to both compliance and participation. Our findings have relevant theoretical implications by establishing measurement and relational equivalence of the NGH model. Practical implications are discussed for managers and practitioners dealing with multi-national organizational contexts. Future research should continue to investigate potential differences in safety related perceptions across additional non-English speaking countries.

Mixed-footedness is a more relevant predictor of schizotypy than mixed-handedness

Mixed-handedness was reported indicative of schizotypy, relevant to psychosis and schizophrenia. However, studies suffered from validity threats and did not systematically investigate associations with footedness. Moreover, there is a dearth of studies in the general population and it is currently untested whether widely used self-report scales measure schizotypy in a comparable way in student and community samples. The present study used two large and independent community and student samples (total N>2800) and utilized latent class analysis (LCA) for the classification of handedness and footedness. Psychometric properties and measurement equivalence of the Schizotypal Personality Questionnaire-Brief form (SPQ-B) in the two samples were also examined. We found that mixed-handedness (<6% prevalence), but also much more common mixed-footedness (25% prevalence), was specifically and similarly associated with higher schizotypy in both samples, Cohen d=0.15-0.18. Findings indicate that schizotypal traits in conjunction with mixed lateral preferences are thus more prevalent in the overall population than previously assumed, and that footedness may be the more relevant predictor of schizotypy than handedness. Findings are further consistent with evidence on neurodevelopmental instability, but also epigenetic mechanisms involving the sex chromosomes, regarding possible common causes of both mixed-handedness and psychosis-relevant traits.

External validity of a generic safety climate scale for lone workers across different industries and companies

PURPOSE

The goal of this study was to examine the external validity of a 12-item generic safety climate scale for lone workers in order to evaluate the appropriateness of generalized use of the scale in the measurement of safety climate across various lone work settings. External validity evidence was established by investigating the measurement equivalence (ME) across different industries and companies.

METHOD

Confirmatory factor analysis (CFA)-based and item response theory (IRT)-based perspectives were adopted to examine the ME of the generic safety climate scale for lone workers across 11 companies from the trucking, electrical utility, and cable television industries.

RESULTS

Fairly strong evidence of ME was observed for both organization- and group-level generic safety climate sub-scales. Although significant invariance was observed in the item intercepts across the different lone work settings, absolute model fit indices remained satisfactory in the most robust step of CFA-based ME testing. IRT-based ME testing identified only one differentially functioning item from the organization-level generic safety climate sub-scale, but its impact was minimal and strong ME was supported.

IMPLICATIONS

The generic safety climate scale for lone workers reported good external validity and supported the presence of a common feature of safety climate among lone workers. The scale can be used as an effective safety evaluation tool in various lone work situations.

The child behavior checklist and youth self-report in adolescents with epilepsy: testing measurement invariance of the attention and thought problems subscales

The objective of this study was to test for the measurement invariance of the Attention and Thought Problems subscales of the Child Behavior Checklist (CBCL) and Youth Self-Report (YSR) in a population-based sample of adolescents with and without epilepsy. Data were obtained from the 14-year follow-up of the Mater University Study of Pregnancy in which 33 adolescents with epilepsy and 1068 healthy controls were included for analysis. Confirmatory factor analysis was used to test for measurement invariance between adolescents with and without epilepsy. Structural equation modeling was used to test for group differences in attention and thought problems as measured with the CBCL and YSR. Measurement invariance was demonstrated for the original CBCL Attention Problems and YSR Thought Problems. After the removal of ambiguous items ("confused" and "daydreams"), measurement invariance was established for the YSR Attention Problems. The original and reduced CBCL Thought Problems were noninvariant. Adolescents with epilepsy had significantly more symptoms of behavioral problems on the CBCL Attention Problems, β=0.51, p=0.002, compared with healthy controls. In contrast, no significant differences were found for the YSR Attention and Thought Problems, β=-0.11, p=0.417 and β=-0.20, p=0.116, respectively. In this population-based sample of adolescents with epilepsy, the CBCL Attention Problems and YSR Thought Problems appear to be valid measures of behavioral problems, whereas the YSR Attention Problems was valid only after the removal of ambiguous items. Replication of these findings in clinical samples of adolescents with epilepsy that overcome the limitations of the current study is warranted.