title: Measuring the expressed emotion in Chinese family caregivers of persons with dementia: Validation of a Chinese version of the Family Attitude Scale.
abstract: BACKGROUND
  Expressed emotion (EE) captures the affective quality of the relationship between family caregivers and their care recipients and is known to increase the risk of poor health outcomes for caregiving dyads. Little is known about expressed emotion in the context of caregiving for persons with dementia, especially in non-Western cultures. The Family Attitude Scale (FAS) is a psychometrically sound self-reporting measure for EE. Its use in the examination of caregiving for patients with dementia has not yet been explored.
  
  
  OBJECTIVE
  This study was performed to examine the psychometric properties of the Chinese version of the FAS (FAS-C) in Chinese caregivers of relatives with dementia, and its validity in predicting severe depressive symptoms among the caregivers.
  
  
  METHODS
  The FAS was translated into Chinese using Brislin's model. Two expert panels evaluated the semantic equivalence and content validity of this Chinese version (FAS-C), respectively. A total of 123 Chinese primary caregivers of relatives with dementia were recruited from three elderly community care centers in Hong Kong. The FAS-C was administered with the Chinese versions of the 5-item Mental Health Inventory (MHI-5), the Zarit Burden Interview (ZBI) and the Revised Memory and Behavioral Problem Checklist (RMBPC).
  
  
  RESULTS
  The FAS-C had excellent semantic equivalence with the original version and a content validity index of 0.92. Exploratory factor analysis identified a three-factor structure for the FAS-C (hostile acts, criticism and distancing). Cronbach's alpha of the FAS-C was 0.92. Pearson's correlation indicated that there were significant associations between a higher score on the FAS-C and greater caregiver burden (r=0.66, p<0.001), poorer mental health of the caregivers (r=-0.65, p<0.001) and a higher level of dementia-related symptoms (frequency of symptoms: r=0.45, p<0.001; symptom disturbance: r=0.51, p<0.001), which serves to suggest its construct validity. For detecting severe depressive symptoms of the family caregivers, the receiving operating characteristics (ROC) curve had an area under curve of 0.78 (95% confidence interval (CI)=0.69-0.87, p<0.0001). The optimal cut-off score was >47 with a sensitivity of 0.720 (95% CI=0.506-0.879) and specificity of 0.742 (95% CI=0.643-0.826).
  
  
  CONCLUSIONS
  The FAS-C is a reliable and valid measure to assess the affective quality of the relationship between Chinese caregivers and their relatives with dementia. It also has acceptable predictability in identifying family caregivers with severe depressive symptoms.
authors.affiliation: The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong. Electronic address: dyu@cuhk.edu.hk.
authors.forename: Doris S F
authors.initials: DS
authors.lastname: Yu
authors.affiliation: Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong. Electronic address: tkwok@cuhk.edu.hk.
authors.forename: Timothy
authors.initials: T
authors.lastname: Kwok
authors.affiliation: The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong. Electronic address: jchoy@cuhk.edu.hk.
authors.forename: Jacky
authors.initials: J
authors.lastname: Choy
authors.affiliation: Faculty of Health, School - Psychology and Counselling, Queensland University of Technology, Brisbane, Australia. Electronic address: david.kavanagh@qut.edu.au.
authors.forename: David J
authors.initials: DJ
authors.lastname: Kavanagh
mesh_terms: D001290:Attitude; D017028:Caregivers / Q000523:psychology*; D002681:China; D003704:Dementia / Q000523:psychology*; D005190:Family / Q000523:psychology*; D005260:Female; D006801:Humans; D008297:Male
keywords: Dyadic relationship; Expressed emotion; Family Attitude Scale; Family caregiving; Persons with dementia