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Evaluating Functional Activity in Older Thai Adults
The purpose of this study was to translate the original English version of the Self-Efficacy and Outcome Expectations Scales for Exercise and Functional Activity and to establish their reliability in older Thai adults in geriatric rehabilitation. This study used a correlational design with repeated measures. Reliability of the Self-Efficacy for Exercise Scale (SEES), the Self-Efficacy for Functional Activity Scale (SEFAS), the Outcome Expectations for Exercise Scale (OEES), and the Outcome Expectations for Functional Activity Scale (OEFAS) developed by Resnick was measured in 20 older adults aged 60 years or older after hip or knee replacement or another orthopedic surgery of their lower extremity. All scales were translated into Thai and back translated into English according to the process described by Marin and Marin. The instruments were administered twice—the 1st and 2nd day in the participants’ geriatric rehabilitation program (i.e., the 4th and 5th postoperative day). Results indicated that there was sufficient evidence for internal consistency of the SEES, SEFAS, OEES, and OEFAS with alpha coefficients of 0.84, 0.86, 0.70, and 0.86 respectively. Test-retest reliability of the tools was also demonstrated with Spearman correlation coefficients of 0.84 for the SEES, 0.87 for the SEFAS, 0.61 for the OEES, and 0.54 for the OEFAS. The findings from this study provide important information for instrument adaptation and the applicability of these scales for further studies of older Thai adults.
Exercise and physical activity are essential strategies that can maintain and restore physical performance and help the independence and well-being of older adults. There has been evidence that exercise and physical activity can lead to improvements in body composition, diminished falls, increased strength, reduced depression, reduced arthritis pain, reduced risks for diabetes and coronary disease, and improved longevity (Christmas & Andersen, 2000). However, older adults do not routinely participate in these activities. In Thailand, for example, less than half of the total number of older adults report performing exercise and physical activity at an acceptable level. For example, 32% report not engaging in exercise and physical activity (Srithunyarat, Arunsang, Chareonchai, Thanasetaungkool, & Pannachet, 2002).
The American College of Sports Medicine and the Centers for Disease Control and Prevention recommend a regular pattern of moderate-intensity physical activity of 30 min or more that may be performed incrementally throughout the day. Older adults should exercise most days of the week. Nurses and other healthcare professionals routinely seek ways to encourage older adults to engage in these beneficial activities. However, older adults often lack a cohesive approach to motivate and support their participation in exercise and physical activity programs. Thus they have unsuccessful or only partially successful outcomes.
A framework is necessary to establish successful (in terms of compliance) and beneficial (in terms of rehabilitation outcomes) exercise and activity programs for older adults. Social Cognitive Theory (SCT) by Bandura (1986, 1997) has been used as a basis for research relating to exercise and physical activity among older adults because it addresses this phenomenon comprehensively. Self-efficacy and outcome expectations, components of the SCT, are important constructs to explain and predict exercise and physical activity behavior among older adults (Conn, 1998; Resnick, Palmer, Jenkins, & Spellbring, 2000; Resnick 2001; Schuster, Petosa, & Petosa, 1995).
Self-efficacy is a central SCT concept and involves individuals’ confidence levels as they perform a particular behavior. Outcome expectations are an important construct for behavioral change because actions are guided by the observed consequences of others or the consequences that people experience themselves (Bandura, 1986). Thus, those people with strong self-efficacy for exercise and functional activity believe they are able to exercise and perform functional activity. Similarly, those with strong outcome expectations for exercise and functional activity believe that exercise and functional activity will produce the desired outcomes of improved physical performance. It is especially important that older adults believe they are able to begin and maintain an exercise program and perform physical activity despite challenges such as pain, joint stiffness, failing balance, or muscle weakness—conditions common among older adults who do not exercise or perform physical activity. Exercise and physical activity programs that fail to acknowledge the importance of self-efficacy and outcome expectations may be doomed to fail.
Physical activity consists of exercise, functional activity, including activities of daily living (ADLs), and other activities that result in increased energy expenditure (Curtis & Russell, 1997). Exercise and physical activity may improve physical performance and overall functioning among older adults (Bassey, 1997; Singh, 2002). Exercise improves physiological function and physical performance by increasing muscle strength, endurance, muscle power, range of motion, and flexibility (Kisner & Colby, 1990). In addition, self-efficacy may be improved through exercise and physical activity, resulting in improved physical performance in both well and ill older adults. Self-efficacy is a strong predictor of exercise and physical activity and thus of physical performance in older adults (Bosscher, Deraa, Dasler, Deeg, & Smith, 1995; Clark, 1999; Conn, 1998; Resnick, Palmer, Jenkins, & Spellbring, 2000; Resnick, 2001; Schuster, Petosa, & Petosa, 1995). Outcome expectations have been found to be less influential than self-efficacy in explaining and predicting health behavior change (Conn, 1998), however, findings were inconsistent, emphasizing the need for further investigation.
Moreover, in conducting research related to exercise and physical activity behavior in Thai culture, self-efficacy and outcome expectation scales are necessary. However, the challenge of measurement is particularly great when investigators study older adults from cultures different from those for whom relevant instruments were originally developed. The Self-Efficacy for Exercise Scale (SEES), Self-Efficacy for Functional Activity Scale (SEFAS), Outcome Expectations for Exercise Scale (OEES), and Outcome Expectations for Functional Activity Scale (SEFAS) were developed for older adults in the United States by Resnick (1996, 1999, 2000). However, one should not assume that merely applying these instruments to older adults of a different culture will produce valid and reliable findings.
Thus, it is essential that the instruments are culturally appropriate, language-specific, and psychometrically tested before they are used in research. Translation is the first step in preparing instruments for cross-cultural research (Yu, Lee & Woo, 2004). The challenge of addressing language issues has been successfully met by the three basic approaches of conducting a translation articulated by Marin and Marin (1991). These approaches include one-way translation, translation by committee, and double translation (i.e., back translation). Back translation is perhaps the best method to produce instruments that are accurate and culturally equivalent to the original version.
This study translates the original English version of the Self-Efficacy and Outcome Expectations Scales for Exercise and Functional Activity (i.e., SEES, SEFAS, OEES, and OEFAS) into Thai. It also establishes their reliability in Thai older adults in geriatric rehabilitation. The research questions examined: (a) the internal consistency of the SEES, SEFAS, OEES, and OEFAS and (b) the test-retest reliability of the SEES, SEFAS, OEES, and OEFAS.
Design and Methods
This study used a correlational design with repeated measures. After the translation process, the instruments were administered twice—once on day 1 of the patients’ rehabilitation program and again on day 2.
The sample consisted of 20 older adults who met the following inclusion criteria: a) men and women age 60 years and older, b) having hip fracture with surgery, knee or hip replacement surgery, or another orthopedic surgery, c) oriented to person, place, and time, and able to sign consent forms, d) no post-operative (PO) complications, e) partial or full weight bearing, f) literate in Thai, and g) participating in the inpatient rehabilitation program and planning to be discharged to home.
This study was conducted at two large hospitals in a metropolitan area of Thailand. The orthopedic ward of each hospital consisted of 40 beds. The medical team (i.e., surgeons, medical residents, and medical and nursing students, together with registered nurses) makes rounds with patients once a day in the morning. One day before surgery, nurses inform the patients about the procedure and teach them the exercise program that they will have to do after surgery. Patients are encouraged to exercise as early as possible after surgery, have early ambulation, and practice walking. The 1st day of rehabilitation for participants in the study was the 4th PO day, when the physicians allowed them to walk and have partial weight bearing. The patients are discharged to home on the 5th or 6th PO day.
Self-Efficacy for Exercise and Functional Activity Scales (SEES, SEFAS)
These scales are 9-item, semantic differential scales with scores ranging from 0 (no confidence) to 10 (total confidence). The scales are scored by summing the numerical rating for each response and dividing the sum by the number of responses.
Outcome Expectations for Exercise and Functional Activity Scales (OEES, OEFAS)
These scales are 6-item, 5-point Likert-type measures with response options ranging from strongly agree (5), agree (4), neither agree nor disagree (3), disagree (2), or strongly disagree (1) with stated outcome benefits of exercise or functional activity. The scales are scored by summing the numerical ratings for each response and dividing the sum by the numbers of responses.
Instrument Translation–Back Translation
All instruments were translated and back translated by two experts who are fluent in both English and Thai. The process articulated by Marin and Marin (1991) was used. Translator A was an educator who is expert in English language and literature with prior translating experience. Translator B was a professor of nursing with prior experience in instrument translation.
Subsequently, the investigators determined that the inconsistencies in the translation were resolved and the instruments were ready for psychometric testing to address the study research questions.
Following approval by the University of Missouri Health Sciences institutional review board and by the directors of the two study hospitals, the principal investigator collected the data. Older adults admitted to the orthopedic wards of each participating hospital from June, 2001 to August, 2001 and who met the eligibility criteria were invited to participate in the study. Their participation was voluntary and confidentiality was emphasized. All patients who met the selection criteria and who were being treated at the hospitals during the study time frame were invited to participate. There were no refusals to participate and there was no attrition during the study.
After the patients agreed to participate in the study and signed the consent forms, a preliminary interview was conducted to complete the demographic questionnaire. Subsequently, the first administration of the SEES, SEFAS, OEES, and OEFAS was conducted on day 1 of the patients’ rehabilitation program (i.e., 4th PO day) and the second administration was on day 2 of their rehabilitation program. Each session was conducted after the subjects’ rehabilitation session at the orthopedic ward. The order of administration of the instruments for day 1 was SEES, SEFAS, OEES, and OEFAS. For day 2, this order was altered to minimize the potential for the maturation effect. The instruments were administered in the following order: SEFAS, SEES, OEFAS, and OEES.
Data were cleaned using double entry comparison. Descriptive statistics were used to analyze the demographic data. Cronbach’s alpha coefficients and Spearman’s correlation coefficients were used to examine the internal consistency and test-retest reliability of the instruments.
Characteristics of the Sample
Tables 1 and 2 show the characteristics of the sample. Most of the participants were female (n = 19) with a mean age of 67.95 and an age range of 60–85. Sixteen participants had osteoarthritis of the knee and were having knee replacement surgery, as is commonly the case in geriatric rehabilitation. All the participants were Buddhist and all lived with other people, such as a daughter (n = 11), or son (n = 5), indicating a typical Thai extended family (Table 1, Table 2).
Reliability of the Instruments
The Cronbach’s alpha coefficient was employed to answer the research question regarding the internal consistency of the SEES, SEFAS, OEES, and OEFAS. The findings demonstrated the alpha coefficients of 0.84 for the SEES, 0.86 for the SEFAS, 0.70 for the OEES, and 0.86 for the OEFAS (Table 3). It was sufficient evidence to support the internal consistency of all instruments (Nunnally & Bernstein, 1994). The Spearman correlation coefficient was calculated to answer the research question regarding the test-retest reliability of each scale. The results are shown in Table 4. Although scores on all the instruments changed between administrations, there were statistically significant correlations between the scores from administration 1 and 2. This provides evidence of the reliability of the SEES, SEFAS, OEES, and OEFAS. However, the test-retest correlation values for the OEES and OEFAS were weaker than those on the SEES and SEFAS (Table 3, Table 4).
The findings provided evidence for the internal consistency of the SEES, SEFAS, OEES, and OEFAS. These were parallel with Resnick’s findings (1996, 1999, 2000) where the internal consistency values with older adults in the United States were 0.92, 0.92, 0.89, and 0.89 respectively (Table 3).
More recently, all of these instruments were re-examined for internal consistency with 63 Thai elders after knee-replacement surgery at the 4th PO day, post-operative weeks 2 and 6 (Harnirattisai, 2003). The findings in that sample showed that the SEES, the OEES and OEFAS were reliable.
The SEFAS performed well at PO day 4; however, it made a weak showing at PO week 2 and PO week 6. The Cronbach’s alpha coefficient of the SEFAS was 0.82 at PO day 4 and 0.64 and 0.49 at PO weeks 2 and 6 (Harnirattisai, 2003; Harnirattisai & Johnson, 2005). These findings revealed that the rating scale used on functional activities (e.g., ADLs such as dressing and bathing) measured by SEFAS might only have been appropriate for the participants at PO day 4, but not PO weeks 2 and 6. The patients might have less pain and could better perform their ADLs in the later phases of rehabilitation (i.e., PO weeks 2 and 6). Moreover, qualitative data in the study by Harnirattisai also revealed that the participants could perform some ADLs however the activities requiring more strength and endurance were difficult activities for them to perform during PO week 4 and PO week 6. These activities were walking with normal gait, longer walking, standing from a chair, and outdoor or social activities. Thus, the SEFAS might not have been internally consistent enough to detect the more subtle changes in self-efficacy occurring during the later phases of rehabilitation. Therefore, if the SEFAS focused on a wider range of more specific activities, such as walking on multi-levels, walking long distances, or changing position from sitting to standing, its sensitivity might be increased.
For test-retest reliability, the present findings demonstrate that scores on all four instruments from Administration 1 were significantly correlated (i.e., strongly for the SEFAS and SEES, and moderately for the OEES and OEFAS) with those from Administration 2 despite minor differences in mean scores between administrations (Table 4). Self-efficacy for exercise decreased and self-efficacy for functional activity increased—the greatest change in mean scores in any of the instruments. Similarly, outcome expectations for exercise increased slightly and outcome expectations for functional activity decreased. One would expect self-efficacy and outcome expectations to increase as the older adults regain strength and functioning.
However, it may have been that the participants had sufficiently less pain on PO day 5 than on PO day 4, or that their rehabilitation activities may have been sufficient to enhance their self-efficacy for functional activity and outcome expectations for exercise. Conversely pain, task difficulty, negative feedback about their performance, observing others exercising, or personality factors may have negatively influenced their outcome expectations for functional activity (Reeve, 1997).
The study procedure was designed to minimize the effects of improvement in the participants’ recovery by using the short re-test interval of 1 day. One inherent risk in this procedure is the chance that participants will remember their responses to Administration 1 and give the same responses in Administration 2. Although it is not possible to determine with certainty that this phenomenon did not occur, in an effort to minimize the risk, the instruments were administered in a different order in Administration 2 than in Administration 1.
The findings from this study provide initial evidence of the internal consistency and test-retest reliability of all four instruments with Thai elders. This evidence and the Thai versions of the instruments make a significant addition to the limited number of instruments available for use by investigators who seek to study this understudied population.
Teeranut Harnirattisai, PhD RN, is an assistant professor, Faculty of Nursing, Thammasat University, Bangkok, Thailand, and can be reached at firstname.lastname@example.org.
Rebecca A. Johnson, PhD RN, is Millsap Professor of Gerontological Nursing, Sinclair School of Nursing, University of Missouri,-Columbia.
Viroj Kawinwonggowit, MD, is associate professor, Diploma Thai Board of Orthopedic Surgery, Faculty of Medicine, Mahidol University, Bangkok, Thailand.
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