Psychological assessment scales for use in community-based research
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Psychological assessment scales for use in community-based research



Đây là các công cụ được sử dụng trong các nghiên cứu về các vấn đề sức khỏe tâm trí ở cộng đồng. Bộ công cụ được sử dụng ở Hội thảo về SKTT ...

Đây là các công cụ được sử dụng trong các nghiên cứu về các vấn đề sức khỏe tâm trí ở cộng đồng. Bộ công cụ được sử dụng ở Hội thảo về SKTT của Trung tâm NCSKCĐ(
Tác giả:
Thai Thanh Truc
Michael Dunne
Linda Murray
Le Tong Giang



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Psychological assessment scales for use in community-based research Psychological assessment scales for use in community-based research Document Transcript

  • HCMC UNIVERSITY OFMEDICINE AND PHARMACYQUEENSLAND UNIVERSITY OFTECHNOLOGYHUE COLLEGE OF MEDICINEAND PHARMACYPsychological assessment scalesfor use in community-based researchThai Thanh TrucMichael DunneLinda MurrayLe Tong GiangNote: This toolkit is a draft which is not yet officially published. It is provided for the workshop onSocial Determinant of Mental Health, Vietnam, Dec 8-10 2011. Participants will receive the finalversion when available.
  • Page 2 of 50PSYCHOLOGICAL ASSESSMENT SCALESOUTLINE1. Introduction2. Reliability2.1.Internal reliability2.2. Test-retest reliability2.3. Interrater reliability2.4. Other types of reliability3. Validity3.1. Content validity3.2. Concurrent validity3.3. Predictive validity3.4. Construct validity3.5. Other types of validity4. Depression scales4.1. Hamilton Depression Rating Scale (HDRS)4.2. Beck Depression Inventory (BDI)4.3. Centre for Epidemiological Studies-Depression (CES-D)4.4. Vietnamese Depression Scale (VDS)4.5. Edinburgh Postnatal Depression Scale (EPDS)5. Anxiety scales5.1. State-Trait Anxiety Inventory (STAI)5.2. Beck Anxiety Scale (BAS)5.3. Self-Rating Anxiety Scale (SAS)5.4. Anxiety Scale used by Vietnamese researchers6. Health risk behavior – Youth Risk Behavior Survey scale (YRBS)7. Educational stress – Educational Stress Scale for Adolescents (ESSA)8. Conclusion9. Appendix 1-1610. Reference
  • Page 3 of 501. IntroductionIn some aspects, psychological issues are so difficult to be assessed. For example,we can measure patients’ blood pressure and then diagnose their cardiovascular statuscorrectly. However, this cannot be done in psychological context. Therefore, we often use“proxies” through which can evaluate patients’ moods as correctly as possible. Theseproxies are called psychological assessment scales. Normally, a psychological scale isinvented through many stages including forming, piloting, testing, modifying. The finalscale which satisfied many of the criteria will give a reasonable accuracy to the event,phenomena measured. The evaluation of the scale in each individual is taken by using ascore which is commonly a three-point scale or 5-point scale or even 10-point scale.Although every psychological rating instrument has its own characteristics, the mostcommon psychometric proprieties used to evaluate these tools are based on reliability andvalidity. Reliability and validity are different aspect of test efficiency (Chadha, 2009, p.156). Reliability often refers to the consistency of the test. In simpler words, reliabilityestimates the degree to which an instrument measures the same way each time it is usedin under the same conditions with the same subjects. Validity, on the other hand, concernsto assessing of outside and independent criteria. This property involves to the degree towhich we are measuring what we are supposed to, more simply, the accuracy of yourmeasurement. In order to be valid, a test must be reliable; but reliability does notguarantee validity. The desired psychological test should have both high reliability andvalidity.This chapter guides you through criteria employed to examine the quality of apsychological scale and gives a more comprehensive look at the psychological assessmentscales that was commonly used in Vietnamese setting with comparison to internationalstudies. The psychometric properties will be investigated mainly based on its reliability,validity as well as its acceptability in term of cross-cultural aspect. The recently conductedstudies by Vietnamese researchers will be used to illustrate and compare the standard ofthe scale in different settings.
  • Page 4 of 502. ReliabilityReliability of a psychological scale relates to the consistency of the scale score indifferent studied population. Even in the same population, the score may be differentevery time we assess the same person. Therefore, the higher reliability a psychological testobtained the freer of error it would be experienced in assessing people’s psychology.Consequently, one of the first things that the researchers should do in psychologicaltesting is to determine whether the scale is reliable enough to be employed in the study(Aiken, 2003, p. 85). The purpose of estimating reliability is to investigate how much of thevariability in test scores is from measurement error and how much is from variability intrue scores. Psychological rating scales should satisfy three types of reliability includinginternal reliability, test-retest reliability and interrater reliability.2.1. Internal reliabilityInternal reliability refers to the assessments of the consistency of results acrossitems within a scale. Cronbach alpha statistic is commonly used to test internal reliability.This inter-item correlation measurement ranges from zero to one. The greater the numberof similar items, the greater the internal consistency the scale has. Because adding moreitems to the scale results in a higher Cronbach’s alpha, researchers sometimes get verylong scales asking one question using different ways. Although alpha of .80 is considered asa reasonable benchmark, in many cases, if this statistics is equal or greater than 0.70 theninternal reliability is considered adequate (L. Cronbach, 1951). On the other hand, theinternal reliability of individual items is often obtained by calculating the corrected item-to-total correlation Pearson’s r (Cohen & Swerdlik, 2005, p. 135).2.2. Test-retest reliabilityTest-retest reliability determines whether multiple administrations of the scale givethe same results (Cohen & Swerdlik, 2005, p. 133). In other word, it illustrates how well theresults from one administration of the test compare to the results from anotheradministration of the same test later. If scores on a scale change in response to effectivetreatment, it is necessary to show that these scores are still similar without the treatment.The test-retest coefficient is employed to measure this type of reliability. The coefficient
  • Page 5 of 50bases on the correlation of the score obtained in a group of participants using oneadministration with their score using the second administration of the scale. Because thepractice effect appears when respondents learn to answer the same questions in the firsttest, if the interval between the two tests is short enough, there is a tendency of a largercoefficient. The correlation also ranges from zero to one and a better scale will have ahigher coefficient. Normally, values of the coefficient from 0.70 to 0.80 are consideredsatisfactory and good (Rousson, Gasser, & Seifert, 2002).2.3. Interrater reliabilityInterrater reliability, on the other hand, assesses the extent to which multiple ratersgenerate the similar results. Because human is not as correct and consistent over time as amachine, whenever researchers have more than one rater in measurement procedure,they will worry about whether the results obtained are reliable or consistent. If variousraters do not agree then either the scale is defective or the raters need to be calibrated.While Pearson’s r is often used to calculate this type of reliability, the intraclass correlationmethod allows adjustment for agreement by chance. Further, many researchers usedCohen’s kappa or Fleiss’ kappa for testing interrater agreement. Contrary to Cohen’s kappawhich only works when assessing the agreement between two raters, Fleiss’s kappa canassess the agreement between a fixed numbers of raters. Estimates of interrater reliabilityshould be equal or greater than 0.70 (Pearson’s r) or 0.60 (intraclass correlation and kappa)(Aiken, 2003, pp. 85-94; Landis & Koch, 1977).2.4. Other types of reliabilityApart from the reliability measurements above, there are other methods such asalternate form method or split-half method. In alternate form, the administer employedtest A for a group and then use another test B to the same group. The correlation betweenthe two scores is the estimate of the test reliability in this method. Because of usingseparate test, this method could make the study more complicated and expensive thantest-retest method (Murphy & Davidshofer, 2005, p. 125). On the other hand, split halfmethod refers to the relationship between half the items of the scale and the other half.This method is a modification of alternate form method but use two half rather than two
  • Page 6 of 50tests. The total test will be then used to estimate the reliability. However, if there aresystematical differences between responses to the first half and those to the second half,the split cannot ensure a very good estimate of reliability. Because of the complicatedfeature of these methods as well as the difficulties in using them in practice, they are notpopularly used.Further, it is also important to know the factors that affect the reliability of apsychological test. The main factors normally are the variability of age, variability of score,time interval between testing, effect of practice and learning, consistency in scores andeffect of test length or the duration of interview session (Chadha, 2009, p. 140).3. ValidityWhile reliability is concerned with the accuracy of the actual measuring test, scaleor procedure, validity refers to the extent to which evidences and theories support theinterpretations of test scores. In other word, it determines to whether a study is able toscientifically answer the questions it is intended to answer. Validity is not examined by asingle statistic, but by a body of research showing the relationship between the test andthe event it is intended to measure. Validity of psychiatric rating scales can be affected bygroup differences, correction of attenuation, criterion contamination and test length(Chadha, 2009, p. 146). Therefore, the validity of a scale should cover the content,concurrent, predictive and construct validity.3.1. Content validityContent validity explains the extent to which a measurement reflects the specificintended domain of content (Aiken, 2003, p. 95). Individual questions may be drawn froma large pool of items that cover a broad range of topics but a test has good content validityonly if the items on the test represent the entire range of possible items the test shouldcover. Content validity can be assessed by examining scale items to determinecorrespondence with known features of symptoms (Cohen & Swerdlik, 2005, pp. 159-162).
  • Page 7 of 503.2. Concurrent validityConcurrent validity is a measure demonstrating how well a test correlates with apreviously validated measure. Concurrent validity applies to validate studies in which twomeasures are administered at approximately the same time. This type of validity comparesscores on an instrument with current performance on some other measure. The resultingcorrelation would be a concurrent validity coefficient. Concurrent validity is regarded as afairly weak type of validity, and is rarely accepted on its own. The problem with concurrentvalidity is that the benchmark test may have some inaccuracies and, if the new test revealsa correlation with the previous test, it might merely show that the new test contains thesame problems as previous one.3.3. Predictive validityPredictive validity of a psychological test is a measure of agreement between resultsobtained by the evaluated measurement and results obtained from more direct andobjective instrument. Predictive validity is commonly used when exploring data inpsychological study as it is employed to collect information about various populations, andto create prediction or generalizations which may be useful when assessing individuals.The correlation coefficient between the two sets of measurements is normally used toassess predictive validity. For example, predictive validity for symptom severity measures isdetermined by a statistically significant capacity to predict change with treatment (Aiken,2003, p. 96).3.4. Construct validityConstruct validity seeks agreement between a theoretical concept and a specificmeasuring device or procedure. Construct validity is not simply illustrated by a singlecoefficient (L. J. Cronbach & Meehl, 1955). However, it can be assessed through otherevidences such as content validity, inter-item correlations, studies of stability over time orunder treatments (L. J. Cronbach & Meehl, 1955). Construct validity can be divided intotwo categories: convergent validity and discriminate validity. Convergent validity is theactual general agreement among ratings where measures should be theoretically related.Convergent validity is adequate when a scale shows Pearson’s r-values of at least 0.50 in
  • Page 8 of 50correlations with other measures of the same symptoms (Loewenthal, 2001, p. 72). On theother hand, discriminate validity concerned to the lack of association among measureswhich theoretically should not be related. Discriminant validity show that the scale can beused to differentiate groups differing in their diagnostic status (Cohen & Swerdlik, 2005, p.179).3.5. Other types of validityOther types of validity include factorial validity and face validity. Factorial validitywhich is a form of construct validity is often tested using factor analysis in order todemonstrate that a meaningful structure can also be established in multiple samples(Cohen & Swerdlik, 2005, p. 180). The loading of 0.40 has been used to identify whichitems are parts of which factors (Loewenthal, 2001, pp. 66-67). Face validity is the leastimportant aspect of validity, because validity still needs to be directly checked throughother methods (Cohen & Swerdlik, 2005, p. 158). Face validity concerns to what a testappears to measure to an individual rather than what it is expected to measured. In otherword, it relates to how a measure or procedure appears such as well design. However, if atest does not have good face validity, there is a tendency of negative consequencesobtained from the study (Cohen & Swerdlik, 2005, p. 158).4. Depression scalesThe general definition of depression is a psychological disorder that affects apersons mood changes, physical functions and social interactions. There is not muchdifference in others definitions but (World Health Organization, 2010) defines depressionas “a common mental disorder that presents with depressed mood, loss of interest orpleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, andpoor concentration.” According to American Psychiatric Association, depression is alsoconsidered not merely a syndrome but an illness that can affect every part of our lifeespecially adolescent and children who may be harmed in the relationships among familymembers and friends, school performance or general health problems such as eating,sleeping, and exercise disorder (American Psychiatric Association, 2010). Because of the
  • Page 9 of 50different definitions and understanding of depression, scales used to evaluate in somewhatdiffer each other. However, each scale has its own advantage and disadvantage, whichmeans it may be the best for a certain setting but has less power for other contexts. Thecombination of these scales is often considered in many researches.4.1. Hamilton Depression Rating Scale (HDRS)AUTHOR : Max HamiltonPURPOSE : Designed to study depressionPOPULATION : patients diagnosed as suffering from depressive symptomsPUBLICATION DATE : 1960ACRONYM : HDRSSCORE : 5-point scale (0-absent to 4-severe) or 3-point scale (0-absent to 2-clearly present)ADMINISTRATION : self-administered questionnaireTIME TO ADMINISTER : 15-20 minutesSUGGESTED USES : Recommended for studying depression in research and clinical settingsThis is also called Hamilton Depression Scale and is abbreviated to HAM-D. Theoriginal version of this scale has 17 questions (HDRS-17) but others later developed scaleshad different number of questions (Hamilton, 1960). This is not only because researcherswanted to make the scale consistent with current definition of depression and reflect amore complete and precise evaluation but also because researchers wanted to increasethe reliability and clinical utility of the scale. These versions consist of 6, 7, 8, 21, 24 or 29items (HDRS-6, HDRS-7, HDRS-8, HDRS-21, HDRS-24 and HDRS-29). The HDRS was designedfor use by a trained clinician because of the complexity of depressive symptoms. This scalewas translated into many other languages and used all over the world. The items in originalscale are about depressed mood, guilt, suicide, insomnia (early, middle and delayed), workand interests, retardation, agitation, anxiety (psychic and somatic), somatic symptom(gastrointestinal and general), genital symptom, hypochondriasis, loss of weight andinsight, diurnal variation, depersonalization, paranoid symptoms, obsessional symptoms(Hamilton, 1960) (see appendix 1). There are two scoring scales: 0-4 (0-absent; 1-mild/trivial; 2/3-moderate; 4-severe) and 0-2 (0-absent; 1-slight or doubtful; 2-clearlypresent). A structured interview guide for the questionnaire is available elsewhere(Williams, 1988). The total scores of responses are calculated and transformed to a scale of0-100. The higher the score is, the more depression the interviewee suffers.
  • Page 10 of 50The scale was not only reliable with the internal consistency statistics (coefficiencyalpha) at 0.91 but also well validated. The cut-off score of 17 showed a high sensitivity andspecificity at 94% and 100% respectively (Maruish, Abbott, Achenbach, & Attkisson, 2004,p. 332). After 40 years from the invention, HDRS was reviewed by the author (Bagby,Ryder, Schuller, & Marshall, 2004). The meta research showed the internal reliabilityfluctuated from 0.46 to 0.97 but most of the studies demonstrated a coefficient alphaequal or greater than 0.70 (Bagby, et al., 2004). The interrater reliability as well as retestreliability was also revealed to have high standard. Content validity was poor whereasother validity characteristic such as convergent and discriminant was suitable.In Vietnam, HDRS is used widely especially in mental hospital (see appendix 2 forVietnamese version used by Vietnam National Institute of Mental Health (2010). However,the efficiency of this scale (the reliability, validity) was not taken appropriateconsideration.4.2. Beck Depression Inventory (BDI)AUTHOR : A. T. Beck, C. H. Ward, M. Mendelson, J. Mock and J. ErbauchPURPOSE : Designed to study depressionPOPULATION : psychiatric patients as well as general populationPUBLICATION DATE : 1961ACRONYM : BDISCORE : 4-point scale of none, mild, moderate, and severeADMINISTRATION : Trained interviewers read aloud the questions for the respondents tochoose fromTIME TO ADMINISTER : 15-20 minutesSUGGESTED USES : Recommended for studying depression in research and clinical settingsIf other scales normally cover not only depression but also anxiety and otherrelating issues, the Beck specially focuses on depression (Bowling, 1997, p. 85). The BeckDepression Inventory created by Dr. Aaron T. Beck is a 21-question multiple-choice self-report inventory, one of the most widely used instruments for measuring the severity ofdepression (A. T. Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). In its current versionthe questionnaire is designed for individuals aged 13 and over, and is composed of itemsrelating to symptoms of depression such as hopelessness and irritability, cognitionsincluding sadness, hopelessness, past failure, anhedonia, guilt, punishment, self-dislike,self-blame, suicidal thoughts, crying, agitation, loss of interest in activities, indecisiveness,
  • Page 11 of 50worthlessness, loss of energy, insomnia, irritability, decreased appetite, diminishedconcentration, fatigue, lack of interest in sex (appendix 3). The scale was shown to havehigh degree of reliability and validity as well as the ability to be applied effectively forpatients with various degree of depression (A. T. Beck, et al., 1961). Twenty five years later,the scale was evaluated through a meta-analysis (Aaron T. Beck, Steer, & Carbin, 1988).The evaluation once again confirm the power of this tool in differentiate subtypes ofdepression. This is not only because of the high coefficient alpha (0.86) together with test-retest reliability statistic (0.60) but also because there is evidence showing strong positiverelationships of this scale with other well-known tools such as Hamilton Rating Scale forDepression, the Zung scale… (Aaron T. Beck, et al., 1988).In Vietnam, although Vietnamese version of BDI was used in most of mental healthhospital, the psychometric of this tool in this population was not investigated properly (seeappendix 4 for the Vietnamese version used by Vietnam National Institute of MentalHealth (2010).4.3. The Centre for Epidemiological Studies-Depression (CES-D)AUTHOR : Lenore Sawyer RadloffPURPOSE : Designed to study depressionPOPULATION : general populationPUBLICATION DATE : 1972ACRONYM : CES-DSCORE : 4-point scale (0-rarely or none of the time, 1-some or little of the time, 2-occasionally or a moderate amount of the time, 3-most or all of the time)ADMINISTRATION : self-administered questionnaireTIME TO ADMINISTER : 15-20 minutesSUGGESTED USES : Recommended for studying depression in epidemiological studiesLike other scale used to assess depression but CES-D is a better choice for use tomeasure depression in general population (Radloff, 1977). In fact, this scale can also beused for other population such as psychiatric samples (Weissman, Sholomskas, Pottenger,Prusoff, & Locke, 1977). CES-D consists of 20 questions which were extracted from a poolof questions from other validated depression scale. The major component of this scaleincludes depressed mood, feelings of guilt and worthiness, feelings of helplessness andhopelessness, psychomotor retardation, loss of appetite and sleep disturbance. Each itemscore ranges from zero to three on a frequency of occurrence scale of the symptom over
  • Page 12 of 50the past week (0-rarely or none of the time; 1-some or a little of the time; 2-occasionally ora moderate amount of time; 3-most or all of the time) (appendix 5). Therefore, the scorerange from zero which means non-symptom experienced over the last week to 60 whichindicate suffer from the symptom all the time over the past week. The higher the score is,the more symptoms of depression occur during the past week. The commonly used cut-offpoint which indicates a depression status is 16 (Chiu et al.; Maruish, et al., 2004, p. 363;Radloff, 1977). This scale was found to have very high internal consistency (coefficientalpha is about 0.85 for general population and 0.90 for patient sample) and adequate test-retest repeatability. The scale also has strong validity which was tested based on thecorrelations with clinical ratings of depression, and on relationships with other factorswhich support its construct validity (Radloff, 1977).In Vietnam context, many researchers used this scale because of its power inpopulation health study. However, it is acknowledge that such a scale is often affected bythe context in which it is used and the translation of the original version may also changethe efficiency of the test (Kinzie, et al., 1982). For example, many researches, which usedEnglish version, showed a better reliability statistics, normally ranges from 0.8 to 0.9(Maruish, et al., 2004, p. 364). The Vietnamese version of CES-D in a research by Quynh(2009) showed a coefficient alpha of 0.72 which is smaller than the original one. On theother hand, Vietnamese version used by Phuong (2007) and Nguyen (2006) showed ahigher value of consistency test at 0.82 and 0.85 respectively. This difference may due tothe target population, which the scale applied to (i.e the differences in age, background…)(Chadha, 2009, p. 140). It is encouraging to know that interviewees in (Quynh, 2009)research were university students who are older and had better education backgroundcompared to school children in (Phuong, 2007) research. However, the translation of CES-Din these authors’ research is in somewhat different. In questionnaire used by Quynh(2009), author mentioned in each question about the symptom in the past week (“Trongtuan vua qua” ~ “in the past week”) whereas (Phuong, 2007) only included these words inthe last five questions (see appendix 6). Furthermore, it was revealed from previousresearches that if the cross-cultural translation procedure (independent forward-and-backward translation between English and Vietnamese) were carried out properly, the
  • Page 13 of 50reliability of the scale would be higher. For instance, with the same scale (CES-D) in adifferent version, the research by Thanh, Dung and Kerry (2003) in Vietnamese Americanpopulation showed a high reliability level (0.9 in community sample and 0.91 in nationalsample). This result is the same in research by Tran (1993) with coefficient alpha at Vietnamese Depression Scale (VDS)AUTHOR : Kinzie, J. D., Manson, S. M., Vinh, D. T., Tolan, N. T., Anh, B., & Pho, T. N.PURPOSE : Designed to study depressionPOPULATION : general populationPUBLICATION DATE : 1982ACRONYM : VDSSCORE : 3-point scale, a cut-off at 13 used to indicate depressive symptomsADMINISTRATION : self-administered questionnaireTIME TO ADMINISTER : 15-20 minutesSUGGESTED USES : Recommended for studying depression in Vietnamese populationVietnamese was believed to have tendency of high score on somatic items such asrespiratory, skin and gastrointestinal using other scales while scores on depression scalewas often low and inconsistent. Therefore, in the United States, (Kinzie, et al., 1982)developed a better scale for depression used only for Vietnamese called “VietnameseDepression Scale” which is abbreviate as VDS. The scale took into account the Vietnamesecultural aspect in order to evaluate depressed individual as well as depressed patientsthrough their thoughts, feelings and behaviors and common clinical characteristics. VDScontains 15 items which was extracted and tested from 43-item scale. The process of thisscale’s development was also interesting. At first, the author and colleagues translatedBeck Depression Inventory items into Vietnamese. However, these items were seemed notto be reliable and acceptable to diagnose depression among Vietnamese community. TheVDS was then invented by a group of specialists in different fields such as psychiatrist,anthropologist, and Vietnamese mental health worker. These experts also experiencedcross-cultural aspect, thus, the scale covered the complexity of perceptions of symptomsand behaviors of this population. This 15-item scale includes desperate (“tuyet vong”),downhearted and low-spirited (“xuong tinh than”), sad and bothered (“buon phien”),feeling of “going crazy” (“muon dien len”), subjective perception of suffering from physicalsymptoms of headache, limb ache or backache (“bi nhung trieu chung dau nhuc”),
  • Page 14 of 50shameful and dishonored (“nhuc nha”), decreased appetite (“an khong ngon mieng”),fellings that the future is hopeless (“that vong”), bothered (“buc”), sad (“buon”), angry(“gian”), inability to concentrate (“khong the tap trung tu tuong duoc”), low-spirited andbored (“nan chi”), diurnal variation (“cam thay kho chiu vao buoi sang hay chieu”),exhausted (“kiet suc”) (Kinzie, et al., 1982). The three-point scale was used to score theseitems. The score of 13 was suggested to determine indicative depression symptoms.Since the time of being invented, the scale was well validated and used by otherresearchers. The research by Lin, Ihle and Tazuma (1985) used this scale to evaluatedepression in Vietnamese refugee population in primary care clinic. Then, in the researchby Kirk Felsman, Leong, Johnson and Crabtree Felsman (1990), this assessment instrumentwas employed to investigate distress in adolescent and young adult. However, in thisstudy, the author raised the question about the construct validity of this tools inassessment of depression (Kirk Felsman, et al., 1990). After that, (Buchwald, Manson,Dinges, Keane, & Kinzie, 1993) conducted a research in ten public health clinic in fourstates to estimate and assess depressive symptoms of Vietnamese refugee population. Thisrating scale was also used in a research by Hinton et al (1994) to validate and compare VDSwith Indochinese Hopkins Symptom Checklist Depression Subscale (HSCL-D). The resultshowed that VDS had sensitivity, specificity, positive predictive value, and negativepredictive value at 64%, 98%, 75% and 97% respectively at standard cut-off point. Thecorresponding values for the HSCL-D was 86%, 93%, 48%, and 99% respectively (Hinton, etal., 1994).4.5. Edinburgh Postnatal Depression Scale (EPDS)AUTHOR : Cox, J. L., Holden, J. M., & Sagovsky, R.PURPOSE : Designed to study postnatal depressionPOPULATION : mother after deliveryPUBLICATION DATE : 1987ACRONYM : EPDSSCORE : 4-point scale, a cut-off at 13 used to indicate depressive symptomsADMINISTRATION : self-administered questionnaireTIME TO ADMINISTER : 5 minutesSUGGESTED USES : Recommended for studying postnatal depression in community
  • Page 15 of 50The EPDS was developed to investigate postnatal depression in the community (CoxJ. L., Holden J. M., & Sagovsky R, 1987) among childbearing women who might have somesymptoms of psychiatric disorder as the result of childbearing. The scale has 10 items andemploys a 4-point answering option from 0 to 3. The score of the items 3 and 5 – 10 haveto be reversed before calculating the total score which ranges from 0 to 30. The scale wasshowed to have good reliability with split-half reliability coefficient of 0.88 while criterionvalidity was established. The threshold of 10 was suggested for routine use in primary caresettings while a cut-off of 13 was an indicator of severe depressive illness.Although this tool was developed to measure depression, however, some recentstudies suggested that EPDS may measure both depression and anxiety (Jomeen andMartin, 2005, Brouwers et al., 2001). Three factor structures of the EPDS have beenreported, including a single-factor model, two-factor model and three-factor model.Interestingly, even in the same factor structure model, the number of items in each sub-scale is very different (Small et al., 2007, Jomeen and Martin, 2005). In Vietnam, there is astudy conducted on 506 postnatal women aged 16-49 years in Ho Chi Minh City tomeasure the Depressive symptomatology (Fisher et al., 2004). In this study, in order toinclude appropriate local linguistic expressions, item 6 and 10 were modified. The resultsshowed that 33% had EPDS scores in the clinical range of >12 and 19% acknowledgedsuicidal ideation. However, the researchers did not mention the reliability and validity ofthis scale to measure depression symptoms of postnatal women in Vietnam context. Inanother survey in Vietnam by Linda Murray et al (2011) this scale revealed high internalconsistency reliability (alpha = 0.82). The factor model by Pop et all (1992) with a three-factor model fit the data well, in which item 1 and 2 load onto Factor 1 (anhedonia); item3, 4, 5 and 6 load onto Factor 2 (anxiety) and item 7, 8, 9 and 10 load onto Factor 3(depressive mood/self harm). Although the factorial validity was established, theunstability of the model structure should also be checked in future researches in Vietnam.Apart from the above scales which is commonly used in Vietnamese setting, otherscales were also employed including Phan Vietnamese Psychiatric Scale (PVPS) (Phan,Steel, & Silove, 2004), Self-Reporting Questionnaire (SRQ-20) (Giang, Allebeck, Kullgren, &van Tuan, 2006).
  • Page 16 of 505. AnxietyAccording to WHO, anxiety is defined as “one of the feelings all of us experiencewhen we are under physical, social, economical, psychological stress” (World HealthOrganization, 2001). This unpleasant feeling is typically associated with uneasiness,apprehension, fear or worry. Anxiety may result in a feeling of impending doom, drynessof mouth, sweating, restlessness, racing heart, butterflies in the stomach, itching andtingling all over the body, shortness of breath, having to visit the bathroom repeatedly,inability to concentrate, make decisions, carry out work, eat or sleep. Another view is thatanxiety is "a future-oriented mood state in which one is ready or prepared to attempt tocope with upcoming negative events" (Barlow, 2000). Anxiety is considered a normalreaction to stress. It may help a person to deal with a difficult situation, for example atwork or at school, by prompting one to cope with it. When anxiety becomes excessive, itmay fall under the classification of an anxiety disorder (US National Institute of mentalHealth, 2010).Anxiety disorders include panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, and phobias (social phobia,agoraphobia, and specific phobia). Approximately 40 million American adults ages 18 andolder, or about 18.1 percent of people in this age group in a given year, have an anxietydisorder (Kessler, Chiu, Demler, & Walters, 2005). Anxiety disorders gave explanation for85% of disorders reported by children and 88% of disorders reported by parents inVietnamese population living in Australia (Wagner, Manicavasagar, Silove, Marnane, &Tran, 2006). Further, Vietnamese patients displayed a range of primary diagnoses,including anxiety disorders at about 59% (McKelvey et al., 2002). Although there was nodefinite proportion of anxiety in Vietnam, Vietnamese researchers showed a high rate ofanxiety children, students in recent years (Dat, 2009; Nguyen, 2006; Phuong, 2007; Quynh,2009).
  • Page 17 of 505.1. State – Trait Anxiety Inventory (STAI)AUTHOR : Charles D. Spielberger, Richard L. Gorusch, and Robert E. Lushene.PURPOSE : Designed to study anxietyPOPULATION : Grades 9-16 and adultsPUBLICATION DATE : 1964ACRONYM : STAISCORE : 40 items (4 point scale) including state anxiety (A-State) and trait anxiety (A-Trait)ADMINISTRATION : self-administered questionnaireTIME TO ADMINISTER : 10-20 minutesSUGGESTED USES : Recommended for studying anxiety in research and clinical settings;Psychometric properties of Vietnamese version should be checked.The State-Trait Anxiety Inventory was initially introduced as a research instrumentto study anxiety in adults. It is frequently used and appears in thousands of studiesexamining anxiety status. This self-reported assessment scale includes separate measuresof state and trait anxiety asking the participants to report how frequently they experiencespecific symptoms of anxiety before, during and after examinations. State anxietyconcerned to the transitory emotional state which may change over time and can vary inintensity while trait anxiety refers to a general tendency to respond with anxiety toperceived threats in the environment. A 4 point scale is used to rate state anxiety (1-Not atall, 2-A little/Somewhat, 3-Moderately so, 4-Very much so) and trait anxiety (1- AlmostNever, 2-Sometimes, 3-Often, 4-Almost Always). The higher the score corresponds to moretrait or state anxiety (Hedberg, 1972). In convention, the score greater than 64 isconsidered anxiety disorder.With respect to reliability, the consistency of the STAI scales was assessed by usingtest-retest reliability, internal reliability, inter-item reliability. The scale was reasonablyreliable with the test-retest coefficients were 0.86 and 0.54 in Trait and State scale for theretest period of 20 days (Hedberg, 1972). The internal consistency was illustrated by thecoefficients of 0.86 and 0.83 for trait and state scale respectively while inter-itemcorrelation was 0.46 and 0.61 for those scales. The state anxiety scale had a lower level ofreliability as responses to the items on this scale are assumed to have an effect fromtransient situational factors exist at the time of testing.Validity, on the other hand, was evaluated through concurrent validity andconstruct validity. This scale was highly correlated with other scales such as Manifest
  • Page 18 of 50Anxiety Scale and IPAT Anxiety Scale with the correlation coefficient from 0.75 to 0.85 instudents and psychiatric patients (Hedberg, 1972). Because the state anxiety itemsconsistently change with different experimental states while trait anxiety items do not,construct validity is reasonably satisfied. Further, the original scale was also well organized,comprehensive with a clear manual instruction which contributed to face validity.The State-Trait Anxiety Inventory was translated and standardized in many otherlanguages such as French, Dutch, Chinese, Polish which were also demonstrated high valueof reliability and validity. For example, in Malaysian version of STAI the individual itemconsistency coefficient ranged from 0.38 to 0.89 while the Cronbachs alpha for the wholetest was 0.86 (Quek, Low, Razack, Loh, & Chua, 2004). In addition, the Greek version highlysatisfied psychometric properties with an Cronbach’s alpha ranged from 0.73 to 0.85 and ahigh level of test-retest reliability as well as inter-scale reliability. On the other hand,although Vietnamese version of STAI is used commonly even in teaching and doingresearch, to the best of our knowledge, it is not well investigated the psychometricproprieties especially in Vietnamese settings (see appendix for Vietnamese version of thisscale used for teaching psychology by Thai Nguyen University of Medicine.5.2. Beck Anxiety Inventory Scale (BAS)AUTHOR : Aaron T. Beck, Norman Epstein, Gary Brown and Robert A. SteerPURPOSE : to study anxietyPOPULATION : psychiatric population or general population (adults as well as adolescents)PUBLICATION DATE : 1988ACRONYM : BAISCORE : 21 items using 4 point scale (0-not at all, 1-mildly, 2-moderately, 3-severely)ADMINISTRATION : self-administered questionnaireTIME TO ADMINISTER : 10-15 minutesSUGGESTED USES : Recommended for studying anxiety in clinical settings; take this test only when theparticipant feels relaxed and calm; Psychometric properties of Vietnamese versionshould be checked.The Beck Anxiety Inventory is a multiple-choice self-administered scale invented byDr Aaron Beck to measure the severity of individual’s anxiety. Beck developed thisinstrument to provide advantageous scale over contemporary scale such as STAI andZung’s Self-rating Anxiety Scale which might have explicitness in assessing depression andanxiety. It can be used on adults as well as adolescents. The scale contains 21 questionsreferring to a variety of anxiety symptoms such as fear, difficulty breathing, numbness and
  • Page 19 of 50tingling. Each of the items have a possible choice of 4 answer to pick from, ranging from 0(not at all/ never) to 3 (severely/always). These questions relates to how strongly you haveexperienced the mentioned feelings over the past week and 3 being severely. The totalscore obtained from the test shows the level of anxiety in which the lower therespondents’ score are, the lesser severity of anxiety they suffered from. As a rule ofthumb, 0-7 represents for minimal level of anxiety, 8-15 for mild anxiety, 16-25 formoderate anxiety and 26-63 for severe anxiety.The Beck Anxiety Inventory showed a high internal consistency with coefficientCronbach’s alpha of 0.92 and the coefficient of test-retest reliability in a period of oneweek was 0.75 (A. T. Beck, Epstein, Brown, & Steer, 1988). Further, the individual itemcorrelation ranged from 0.30 to 0.71 which showed a reasonable reliability. Applied indifferent populations, the Beck ‘s scale also remained a high level of reliability. Forexample, in non-clinical population such as undergraduate students, this scale showed ahigh internal consistency with the coefficient 0.91 while test-retest correlation for a periodof seven weeks was still good at 0.62 (Creamer, Foran, & Bell, 1995). Particularly,employed in general population, Beck’s scale even had a better level of internalconsistency (alpha = 0.93) (Magán, Sanz, & García-Vera, 2008).The validity of the scale was demonstrated by the relationship with the revisedHamilton Anxiety Rating scale (will be mentioned later) with the correlation coefficient of0.51. In addition, the factorial validity as well as construct validity was also checked. Theresult revealed a high standard of convergent and discriminant validity. Although the items“terrified” had a loading on depression factor in factorial validity, the rest of the item ofscale indicated a high contribution to assessing anxiety (A. T. Beck, et al., 1988). Otherstudies conducted to examine BAI’s validity also provide more evidences to thispsychometric property of the scale including construct validity, concurrent validity as wellas factorial validity (Creamer, et al., 1995; Hewitt & Norton, 1993; Morin et al., 1999).Further, the translated versions of this Beck Anxiety Inventory remained highconsistency property such as Turkish version (alpha = 0.93) (Ulusoy, Sahin, & Erkmen,1998), Spanish version (alpha = 0.93) (Magán, et al., 2008) or French version (alpha = 0.85)(Freeston, Ladouceur, Thibodeau, Gagnon, & Rheaume, 1994). In these studies, the validity
  • Page 20 of 50also is checked using factorial analysis. The results also confirmed the validity of BAI scale(Magán, et al., 2008; Ulusoy, et al., 1998).5.3. Self-Rating Anxiety Scale (SAS)AUTHOR : Zung William W.KPURPOSE : to explore anxiety statusPOPULATION :PUBLICATION DATE : 1971ACRONYM : SASSCORE : 20 items using 4 point scale (1-none, 2-mild, 3-moderate, 4-severe)ADMINISTRATION : self-administered questionnaireTIME TO ADMINISTER : 15-20 minutesSUGGESTED USES : Recommended for studying anxiety in research and clinical settings;Psychometric properties of Vietnamese version should be checked.The Self-Rating Anxiety Scale was introduced by William WK Zung to examine thelevel of anxiety for people experiencing anxiety related symptoms (Zung, 1971). This self-administered test has 20 questions asking respondent to rate their symptoms during thepast week. Some of the items examine the symptomatically negative aspects while othersrefer to positive. There are fifteen questions worded toward increasing anxiety levels andfive questions worded toward decreasing anxiety levels. Each question is rated on a 4 pointscale (1-none or a little of the time, 2-some of the time, 3-good part of the time, 4-most ofthe time). Thus, the scores range from 20-80. The lower score the respondents obtainedfrom the test indicates a less anxious they are. To make it easy in assessing anxiety usingthis score, a simple rule is set as 20-44 represent normal range of anxiety, 45-59 for mild tomoderate, 60-74 for severe anxiety and 75-80 extreme anxiety level.To test the consistency of the scale, Zung used split half and individual itemreliability. The results showed a good level of reliability with split half correlationcoefficient of 0.74 and the individual item correlation coefficient ranged from 0.3 to 0.7(Zung, 1971). Other studies conducted to examine the psychometric proprieties of SAS alsorevealed a high internal consistency reliability coefficient (alpha = 0.80 (Ramirez &Lukenbill, 2008) and alpha = 0.71 (Olatunji, Deacon, Abramowitz, & Tolin, 2006)). However,it is important to see from a study conducted in mental handicap population that theinternal consistency was not satisfied (Lindsay & Michie, 1988). This suggests that this scaleshould be used with caution in mental handicap population.
  • Page 21 of 50The validity of Zung’s Self-Rating Anxiety Scale based on the relationship with otherinstruments such as Taylor Manifest Anxiety Scale. The analysis showed no significantdifference between two scales (Zung, 1971). Further, Olatunji and his colleaguesinvestigated the validity of this scale through factorial validity and convergent validity anddiscriminant validity in undergraduate population (Olatunji, et al., 2006). The resultindicated an adequate convergent validity, factorial validity although a limited discriminantvalidity existed. However, the SAS is believed to cover depression symptoms rather thananxiety itself (Olatunji, et al., 2006).The Zung’s Self-Rating Anxiety Scale is used in many studies in Vietnamese setting.For example, using this scale, a study conducted in Hanoi investigating anxiety in highschool student revealed that 13.1% students had signs of anxiety. This instrument is alsoused by many mental health institute and hospital (Vietnam National Institute of MentalHealth, 2010c). However, because this scale does not clearly differentiate anxiety anddepression symptoms and the fact that psychometric proprieties of this scale was notexamined properly, using this scale may lead uncertain result.5.4. Anxiety Scale used by Vietnamese researchersAUTHOR : Nguyen, Huong ThanhPURPOSE : to explore anxiety statusPOPULATION : Vietnamese children and adultPUBLICATION DATE : 2006ACRONYM : NilSCORE : 13 items using 3 point scale (1-never, 2-sometimes, 3-often)ADMINISTRATION : self-administered questionnaireTIME TO ADMINISTER : 5 minutesSUGGESTED USES : recommended for use in Vietnamese settingIn recent years, many studies were carried out in Vietnamese setting investigatinganxiety not only in children but also in university students (Nguyen, 2006; Quynh, 2009). In2006, Nguyen H. T. introduced an anxiety scale in her study called “Child maltreatment inVietnam: prevalence and associated mental and physical health problems”. According toNguyen, because there was “no validated or locally developed” anxiety scale available foruse in Vietnamese setting and there was a need for a short and concise form of anxietyassessment, she used a 13 item scale which is extracted from other international scalessuch as STAI, SAS. The scale initially had 16 questions but then was shorten based on pilot
  • Page 22 of 50study. This instrument used a three point scale (1-never, 2-sometime, 3-often) which mayresult in a total score from 13 to 39. The higher the score is, the more anxious therespondents suffer.With respect to others psychometric properties, Nguyen reported an internalconsistency coefficient of 0.79 which was adequate for a psychological rating scale(Nguyen, 2006). Further, other studies also showed high internal consistency using thisscale. The examples include studies on mental health in university students conducted byQuynh (2009) and Dat (2009) which showed the Cronbach’s alpha of 0.78 and 0.76respectively or the mental health study in school children by Phuong (2007) with a internalreliability coefficient of 0.81. However, these studies added one more question to the scalewhich was “I worried about my relationship with my partner”. On the other hand, thevalidity of this scale was also checked by using factor analysis. The result revealed threeaspects of anxiety explored using this scale including fears, tension and worries. Theloadings of these three factors were reasonably high which one again confirms a goodstandard scale. However, because the initial purpose of this scale was to use to assessanxiety for Vietnamese population, the English version of this scale should be checked tomake results more exact in studies in international settings.6. Health risk behaviorPsychological issues in public health perspective implicate more than the present ofmental illness. These include the health risk behaviors which may be caused by theinteraction of many social, behavioral, psychological health problem. As a definition, healthrisk behavior involves actions and related knowledge and attitudes that contribute topeoples tendency to engage in, or avoid, activities that have been deemed by experts tobe hazardous or dangerous to their health (DiClemente, Hansen, & Ponton, 1996).Although peoples behaviors are based very much on an individual level but their effectsmay also be harmful to individuals’ family, relatives and communities. For example, aperson may die or become disable because of substance abuse, suicide or violence but theaffect on other people relating to his/her behavior is unmeasurable.
  • Page 23 of 50In Vietnam, in recent years, issues about health risk behavior are being coped andstudied especially in adolescent and children. Researches on these issues revealed that theproportion of respondent reported ever seriously considered attempting suicide was from6.6% to 9.2% (Dat, 2009; Quynh, 2009). Further, research by Nguyen (2006) reported aproportion of 2.8% of students ever accidentally injured while drunk. On the other hand,from 2.3% to 9.2% university students reported having gone without eating for 24 hours ormore in order to lose weight or to keep from gaining weight (Dat, 2009; Quynh, 2009).Other risk behaviors such as have carried a weapon, have been threatened or injured bysomebody with a weapon or have been involved in fighting were also remarkable (Dat,2009; Nguyen, 2006; Phuong, 2007; Quynh, 2009). However, although having the samereference (youth risk behavior survey scale), the short-form scales used to study health riskbehavior in Vietnamese settings seemed to be lightly different and have not been validatedwell.Youth Risk Behavior Survey Scale (YRBS)AUTHOR : Centers for Disease Control and Prevention (USA)PURPOSE : to explore youth risk behaviorPOPULATION : young peoplePUBLICATION DATE : 1990ACRONYM : YRBSSCORE : 87 items (2-8 point scale)ADMINISTRATION : self-administered questionnaireTIME TO ADMINISTER : 35 - 45 minutesSUGGESTED USES : recommended for use in student, Vietnamese version should be validatedQuestionnaire of youth risk behavior survey (YRBS) was developed by the Centresfor Disease Control and Prevention in the United States in 1990 (Centers for DiseaseControl and Prevention, 2007b). The YRBS can be used to track aggregate changes instudent behavior over time which are often established during youth and extend intoadulthood. YRBS covers six domains of priority health risk behaviors including behaviorsrelating to unintentional injuries and violence; tobacco use; alcohol and other drug use;sexual behaviors; unhealthy dietary behaviors; and physical inactivity. When using YRBS,apart from the principle of anonymous and voluntary participation, it is recommended toget parental permission prior to administration of a YRBS so as to protect student privacy.From first use in 1990, the scale was reviewed many times with changes and modificationswhich occur nearly every year. That is why the scale now is considered to be able to
  • Page 24 of 50provide the most effective assessment of the most critical priority health-risk behaviorsamong young persons. The 2005 version of this scale includes 4 items that assessdemographic information; 20 items related to unintentional injuries and violence; 11 itemsabout tobacco use; 18 items about alcohol and other drug use; 7 items about sexualbehavior; 16 items about body weight and dietary behaviors; 7 items about physicalactivity; and 4 items about other health-related topics (Centers for Disease Control andPrevention, 2007a).Reliability of YRBS was examined based on test-retest reliability. Normally, thequestionnaire was administered on two occasions with an interval of 14 days. Although theversion of YRBS changed year by year, the reliabilities of these version were not muchdifferent. For example, psychometric investigation of the 1991 version showed that Kappasranged from 14.5% to 91.1% and most of the items (71.7%) were rated with high level ofreliability (kappa = 61-100%). Further, there were no significant differences between theprevalence estimates at first and second tests (N. D. Brener, Collins, Kann, Warren, &Williams, 1995). With the 2005 version, the mean kappa was 62.6% and the median was66.5% and nine items (24.3%) and one category (alcohol-drugs) had kappas below 61.0%(Zullig, Pun, Patton, & Ubbes, 2006). The result suggested that YRBS was reliable over time.There was no validity investigation on YRBS scale until 2003 when CDC conducted areview of existing empirical literature to assess that factors affecting the validity ofstudents self-reporting of behaviors measured by the YRBS questionnaire (Centers forDisease Control and Prevention, 2004). The research examined whether the self-reportedinformation from students on their weight and height, and body mass index was valid toexplain the behaviors. The results showed a high correlations between self-reported andmeasured height, weight, and BMI suggesting that self-reported height and weight arevalid proxy measures for measured values (Nancy D. Brener, McManus, Galuska, Lowry, &Wechsler, 2003). Furthermore, the validity of other domain in assessing adolescentbehaviors was also checked based on literature review.With respect to non-English version of YRBS, there are many researches conductedusing YRBS in different langluages such as Thai and Vietnamese. The Thai version used byNintachan and Moon (2007) was modified to accurately reflect its relevance among Thai
  • Page 25 of 50adolescents. Some items were changed while the others were removed so as to beapplicable in the Thai setting. The results showed that Thai version has evidence ofsemantic, content, and conceptual equivalence as well as feasibility and acceptability withthe content validity index ranged from 0.89 to 0.98 (Nintachan & Moon, 2007). TheVietnamese version of YRBS, on the other hand, was a short form of YRBS and includedfrom nine to eleven adapted items refer to severe sadness or hopeless, suicidal attempt,suicide planning, cigarette smoking, alcohol drinking, eating disorders and violence-relatedbehaviors (Dat, 2009; Nguyen, 2006; Quynh, 2009) (see appendix 12). However, althoughthis scale was used commonly in Vietnamese researchers, the reliability as well as thevalidity of this version in Vietnamese settings is still a question.7. Eductional Stress Scale for AdolescentsOne of the major contributing factors to poor mental health in adolescence in Asia isacademic stress. In Vietnam, there is a strong perception that the more pressure parentsplace upon children and adolescents, the better their children will perform academicallyand the better life they will have. Although strong parental interest and some pressurefrom parents and teachers on students can yield benefits, there may also be negativeimpacts on health and well-being as children often endure long periods of academicpressure. In recent years, studies worldwide reveal a strong relationship betweenacademic pressure and stress, depression, anxiety, low self-esteem and suicidal ideationamong students in both secondary school/high school and young adults.Sun, Dunne, Hou and Xu (2010) have introduced a scale to evaluate educationalstress in Asian adolescents called the Educational Stress Scale for Adolescents (ESSA). This16-item scale was derived from a pool of 30 items that emerged from qualitativeinterviews and covers five dimensions of educational stress including pressure from study,worry about grade, despondency, self expectation and workload. The scale has goodpsychometric properties and has advantages over other scales used in Asian countries suchas Academic Expectation Stress Inventory – AESI and tools used in Western countries (e.g.Survey of Academic Stress - SAS, High School Stress Scale - HSSS).
  • Page 26 of 50AUTHOR : Sun, J., Dunne, M. P., Xu, A.-q., & Hou, X.-yPURPOSE : to examine educational stress among adolescentsPOPULATION : adolescentsPUBLICATION DATE : 2011ACRONYM : ESSASCORE : 16 items (5-point scale)ADMINISTRATION : self-administered questionnaireTIME TO ADMINISTER : 5-10 minutesSUGGESTED USES : recommended for use in secondary and high school studentsThis 16 item instrument employed 5 point scale from 1 (strongly disagree) to 5(strongly agree). Total scores of ESSA was used including 5 sub-dimensions: pressure fromstudy (4 items), worry about grade (3 items), despondency (3 items), self expectation (3items), and workload (3 items). Cut-off points using tertile suggested by Sun (2010) for lowstress, medium stress and high stress were employed in further analysis. In a survey amongsecondary and high school students in Ho Chi Minh City by Truc et al (2011), the ESSAshowed excellent reliability with Alpha Cronbach of 0.83 although ESSA sub-scales showeda lower range of reliability (from 0.62 to 0.78). Confirmatory factor analysis showed thatfactorial validity was established with 5-factor model. The ESSA had positive correlationwith the CES-D (r = 0.37, p<0.001), the K10 (r = 0.42, p<0.001) and anxiety scale (r = 0.36,p<0.001) and negative correlation with WHO-5 (r = -0.31, p<0.001). This indicates thatthere is some evidence of concurrent validity of the ESSA and psychological constructsrelated to academic stress such as anxiety and depression. Another study by Truc et al(2011) among secondary and high school students in rural areas in Long An provinceshowed the same results (high internal consistency reliability with alpha = 0.85, factorialvalidity and concurrent validity were also confirmed). The ESSA appears to be suitable formeasurement of educational stress in Vietnamese adolescents.8. ConclusionMost of the psychological rating scale suffers from the same problems especiallyself-report inventories. The scores in these scales may be easily exaggerated or minimizedby the person completing them. Furthermore, like all questionnaires, the way participantsadminister the instrument can affect the final score. This reason is especially right inVietnamese setting. For example, if a patient/participant is asked to complete the
  • Page 27 of 50questionnaire in front of other people then social expectations might lead to a differentresponse compared to administration via a postal survey.In Vietnam, although many researches on mental health were conducted, especiallydepression and anxiety as well as psychological risk behavior, there are limited researchesthat evaluate psychometric of rating assessment instrument. Normally, Vietnameseresearchers “invent” their own assessment tools by combining other well-validated scalessuch as BDI, CES-D, HDRS, SAS or VAS. Otherwise, the researches stop at the descriptiveanalysis or testing the relationship of some items with the outcome without taking intoaccount the reliability and validity of the tools they used. Further, although using the samescale, the Vietnamese translation in some researches may differ each other which maycause the different efficiency of the same tool. It is clearly showed that the research whichconducted a good cross-cultural translation procedure normally have a higher efficiency ofthe scale. This is definitely true because psychometric properties of an assessment toolsare affected by the context in which it is used and by the culture and norm in which theparticipants were recruited.However, in recent years, there are great efforts in mental health researchers instandardizing the scales used. The anxiety scale developed by Nguyen or the Phan’sdepression scale are evidences for this effort. Therefore, if the researchers follow the agood translation process as well as a validation process, the scale mentioned in thischapter are believed to be applied successfully in Vietnamese settings in assessing people’smental health.
  • Page 28 of 509. AppendixAPPENDIX 1: HAMILTON RATING DEPRESSION SCALEPLEASE COMPLETE THE SCALE BASED ON A STRUCTURED INTERVIEWInstructions: for each item, select the one “cue” which best characterizes the patient. Be sure to record theanswers in the appropriate spaces (positions 0 through 4).1 DEPRESSED MOOD (sadness, hopeless, helpless, worthless)0 |__| Absent.1 |__| These feeling states indicated only on questioning.2 |__| These feeling states spontaneously reported verbally.3 |__| Communicates feeling states non-verbally, i.e. throughfacial expression, posture, voice and tendency to weep.4 |__| Patient reports virtually only these feeling states in his/her spontaneous verbal and non-verbalcommunication.2 FEELINGS OF GUILT0 |__| Absent.1 |__| Self reproach, feels he/she has let people down.2 |__| Ideas of guilt or rumination over past errors or sinful deeds.3 |__| Present illness is a punishment. Delusions of guilt.4 |__| Hears accusatory or denunciatory voices and/or experiences threatening visual hallucinations.3 SUICIDE0 |__| Absent.1 |__| Feels life is not worth living.2 |__| Wishes he/she were dead or any thoughts of possible death to self.3 |__| Ideas or gestures of suicide.4 |__| Attempts at suicide (any serious attempt rate 4).4 INSOMNIA: EARLY IN THE NIGHT0 |__| No difficulty falling asleep.1 |__| Complains of occasional difficulty falling asleep, i.e. more than 1⁄2 hour.2 |__| Complains of nightly difficulty falling asleep.5 INSOMNIA: MIDDLE OF THE NIGHT0 |__| No difficulty.1 |__| Patient complains of being restless and disturbed during the night.2 |__| Waking during the night – any getting out of bed rates 2 (except for purposes of voiding).6 INSOMNIA: EARLY HOURS OF THE MORNING0 |__| No difficulty.1 |__| Waking in early hours of the morning but goes back to sleep.2 |__| Unable to fall asleep again if he/she gets out of bed.7 WORK AND ACTIVITIES0 |__| No difficulty.1 |__| Thoughts and feelings of incapacity, fatigue or weakness related to activities, work or hobbies.2 |__| Loss of interest in activity, hobbies or work – either directly reported by the patient or indirect inlistlessness, indecision and vacillation (feels he/she has to push self to work or activities).3 |__| Decrease in actual time spent in activities or decrease in productivity. Rate 3 if the patient does notspend at least three hours a day in activities (job or hobbies) excluding routine chores.4 |__| Stopped working because of present illness. Rate 4 if patient engages in no activities except routinechores, or if patient fails to perform routine chores unassisted.8 RETARDATION (slowness of thought and speech, impaired ability to concentrate, decreased motoractivity)0 |__| Normal speech and thought.1 |__| Slight retardation during the interview.2 |__| Obvious retardation during the interview.3 |__| Interview difficult.4 |__| Complete stupor.9 AGITATION0 |__| None.1 |__| Fidgetiness.2 |__| Playing with hands, hair, etc.3 |__| Moving about, can’t sit still.4 |__| Hand wringing, nail biting, hair-pulling, biting of lips.
  • Page 29 of 5010 ANXIETY PSYCHIC0 |__| No difficulty.1 |__| Subjective tension and irritability.2 |__| Worrying about minor matters.3 |__| Apprehensive attitude apparent in face or speech.4 |__| Fears expressed without questioning.11 ANXIETY SOMATIC (physiological concomitants of anxiety) such as: gastro-intestinal – dry mouth,wind, indigestion, diarrhea, cramps, belching cardio-vascular – palpitations, headaches respiratory –hyperventilation, sighing urinary frequency sweating0 |__| Absent.1 |__| Mild.2 |__| Moderate.3 |__| Severe.4 |__| Incapacitating.12 SOMATIC SYMPTOMS GASTRO-INTESTINAL0 |__| None.1 |__| Loss of appetite but eating without staff encouragement. Heavy feelings in abdomen.2 |__| Difficulty eating without staff urging. Requests or requires laxatives or medication for bowels ormedication for gastro-intestinal symptoms.13 GENERAL SOMATIC SYMPTOMS0 |__| None.1 |__| Heaviness in limbs, back or head. Backaches, headaches, muscle aches. Loss of energy andfatigability.2 |__| Any clear-cut symptom rates 2.14 GENITAL SYMPTOMS (symptoms such as loss of libido, menstrual disturbances)0 |__| Absent.1 |__| Mild.2 |__| Severe.15 HYPOCHONDRIASIS0 |__| Not present.1 |__| Self-absorption (bodily).2 |__| Preoccupation with health.3 |__| Frequent complaints, requests for help, etc.4 |__| Hypochondriacal delusions.16 LOSS OF WEIGHT (RATE EITHER a OR b)a) According to the patient:0 |__| No weight loss.1 |__| Probable weight loss associated with present illness2 |__| Definite (according to patient) weight loss3 |__| Not assessed.b) According to weekly measurements:0 |__| Less than 1 lb weight loss in week.1 |__| Greater than 1 lb weight loss in week.2 |__| Greater than 2 lb weight loss in week.3 |__| Not assessed.17 INSIGHT0 |__| Acknowledges being depressed and ill.1 |__| Acknowledges illness but attributes cause to bad food, climate, overwork, virus, need for rest, etc.2 |__| Denies being ill at all.Total score: |__|__|
  • Page 30 of 50APPENDIX 2: HAMILTON DEPRESSION RATING SCALE (Vietnamese version used byVietnam National Institute of Mental Health)Thang HAM-D được xây dựng để đánh giá mức độ trầm cảm của người bệnh. Chỉ tính điểm cho người bệnhở 17 mục đầu tiên.1. TRẠNG THÁI TRẦM(Thái độ rầu rĩ, bi quan về tương lai, có cảm giác buồn bã, khóc lóc).0= Không có triệu chứng1= Có cảm giác buồn chán2= Thỉnh thoảng khóc lóc3= Khóc liên tục4= Các triệu chứng trầm trọng.2. CẢM GIÁC TỘI LỖI0= Không có1= Tự chỉ trích bản thân, thấy mình luôn làm mọi người thất vọng2= Có ý nghĩ tự buộc tội3= Nghĩ rằng bệnh hiện tại là do bị trừng phạt, có hoang tưởng bị buộc tội4= Có ảo giác bị buộc tội.3. TỰ SÁT0= Không có1= Cảm thấy cuộc sống không có ý nghĩa2= Muốn được chết3= Có ý tưởng hoặc hành vi tự sát4= Cố ý tự sát.4. MẤT NGỦ - giai đoạn đầu(Khó đi vào giấc ngủ).0= Không có dấu hiệu1= Đôi khi2= Thường xuyên5. MẤT NGỦ - giai đoạn giữa(Than phiền bị quấy rầy và có cảm giác bồn chồn suốt đêm. Tỉnh giấc trong đêm)0= Không có1= Đôi khi2= Thường xuyên6. MẤT NGỦ - giai đoạn cuối(Thức dậy sớm hơn nhiều giờ vào buổi sángvà không thể ngủ lại được)0= Không có1= Đôi khi2= Thường xuyên7. CÔNG VIỆC VÀ HỨNG THÚ0= Không gặp bất cứ khó khăn gì1= Có cảm giác bất lực, bơ phờ, dao động2= Mất hứng thú vào các sở thích, giảm các hoạt động xã hội3= Giảm hiệu quả công việc4= Không thể làm việc được. Bỏ việc chỉ vì bệnh hiện tại.8. CHẬM CHẠP(Chậm chạp trong suy nghĩ, lời nói, hoạt động, lãnh đạm, sững sờ)0= Không có triệu chứng1= Có một chút chậm chạp trong lúc khám2= Rất chậm chạp trong lúc khám3= Hoàn toàn sững sờ.9. KÍCH ĐỘNG(Cảm giác bồn chồn kết hợp với lo âu)0= Không có1= Đôi khi2= Thường xuyên10. LO ÂU - triệu chứng tâm lý0= Không có triệu chứng1= Căng thẳng và cáu gắt2= Lo lắng vì những điều nhỏ nhặt3= Thái độ lo lắng, bứt rứt4= Hoảng sợ
  • Page 31 of 5011. LO ÂU - triệu chứng cơ thể(Dạ dày, ruột, khó tiêu, tim đạp nhanh, đau đầu, khó thở, đường tiết niệu...)0= Không có triệu chứng1= Triệu chứng nhẹ2= Triệu chứng rõ rệt3= Triệu chứng nghiêm trọng4= Mất khả năng làm việc12. TRIỆU CHỨNG CƠ THỂ - dạ dày và ruột(Mất sự ngon miệng, cảm giác nặng bụng, táo bón)0= Không có1= Có triệu chứng nhẹ2= Triệu chứng nghiêm trọng13. TRIỆU CHỨNG CƠ THỂ CHUNG(Cảm giác nặng nề ở chân tay, lưng hay đầu, đau lưng lan tỏa, bất lực và mệt nhọc)0= Không có1= Triệu chứng nhẹ2= Triệu chứng rõ rệt14. TRIỆU CHỨNG SINH DỤC(Mất hứng thú tình dục, rối loạn kinh nguyệt)0= Không có1= Triệu chứng nhẹ2= Triệu chứng rõ rệt15. NGHI BỆNH0= Không có dấu hiệu1= Quá quan tâm đến cơ thể2= Quá quan tâm đến sức khỏe3= Phàn nàn nhiều về sức khỏe4= Có hoang tưởng nghi bệnh16. SÚT CÂN0= Không bị sút cân1= Sút cân nhẹ2= Sút cân nhiều hoặc trầm trọng17. NHẬN THỨC(Được đánh giá qua trình độ và nền văn hóa của người bệnh)0= Không mất nhận thức1= Mất một phần nhận thức hay nhận thức không rõ ràng.2= Mất nhận thức18. THAY ĐỔI TRONG NGÀY VÀ ĐÊM(Triệu chứng xấu hơn về buổi sáng hoặc buổi tối. Ghi lại sự thay đổi đó).0= Không có sự thay đổi1= Có chút thay đổi: sáng ( ) tối ( )2= Có sự thay đổi rõ rệt: sáng ( ) tối ( )19. GIẢI THỂ NHÂN CÁCH - TRI GIÁC SAI SỰ THẬT(Cảm giác không có thực, có ý tưởng hư vô)0= Không có dấu hiệu1= Triệu chứng nhẹ2= Triệu chứng rõ rệt3= Triệu chứng trầm trọng, bất lực.20.CÁC TRIỆU CHỨNG PARANOID(Không bao gồm các triệu chứng của trầm cảm)0= Không có dấu hiệu1= Nghi ngờ những người xung quanh làm hại mình2= Có ý tưởng liên hệ3= Có hoang tưởng liên hệ và hoang tưởng bị hại4= Có ảo giác, bị hại.21.TRIỆU CHỨNG ÁM ẢNH CƢỠNG BỨC(Những ý nghĩ ám ảnh cưỡng bức chống lại những gì người bệnh đang cố gắng loại bỏ)0= Không có dấu hiệu1= Triệu chứng nhẹ2= Triệu chứng rõ rệt
  • Page 32 of 50APPENDIX 3: BECKS DEPRESSION INVENTORYThis Depression Inventory can be self-scored. The scoring scale is at the end of the questionnaire.Symptoms Answer Score1 Mood I do not feel sadI feel sadI am sad all the time and I cant snap out of itI am so sad and unhappy that I cant stand it01232 Pessimism I am not particularly discouraged about the futureI feel discouraged about the futureI feel I have nothing to look forward toI feel the future is hopeless and that things cannot improve01233 Sense of Failure I do not feel like a failureI feel I have failed more than the average personAs I look back on my life, all I can see is a lot of failuresI feel I am a complete failure as a person01234 Lack ofSatisfactionI get as much satisfaction out of things as I used toI dont enjoy things the way I used toI dont get real satisfaction out of anything anymoreI am dissatisfied or bored with everything01235 Guilty Feeling I dont feel particularly guiltyI feel guilty a good part of the timeI feel quite guilty most of the timeI feel guilty all of the time01236 Sense ofPunishmentI dont feel I am being punishedI feel I may be punishedI expect to be punishedI feel I am being punished01237 Self Hate I dont feel disappointed in myselfI am disappointed in myselfI am disgusted with myselfI hate myself01238 Self Accusations I dont feel I am any worse than anybody elseI am critical of myself for my weaknesses or mistakesI blame myself all the time for my faultsI blame myself for everything bad that happens01239 Self-punitiveWishesI dont have any thoughts of killing myselfI have thoughts of killing myself, but I would not carry them outI would like to kill myselfI would kill myself if I had the chance012310 Crying Spells I dont cry any more than usualI cry more now than I used toI cry all the time nowI used to be able to cry, but now I cant cry even though I want to012311 Irritability I am no more irritated by things than I ever wasI am slightly more irritated now than usualI am quite annoyed or irritated a good deal of the timeI feel irritated all the time012312 SocialWithdrawalI have not lost interest in other peopleI am less interested in other people than I used to beI have lost most of my interest in other peopleI have lost all of my interest in other people012313 Indecisiveness I make decisions about as well as I ever couldI put off making decisions more than I used toI have greater difficulty in making decisions more than I used toI cant make decisions at all anymore012314 Body Image I dont feel that I look any worse than I used toI am worried that I am looking old or unattractiveI feel that there are permanent changes in my appearance thatmake me look unattractiveI believe that I look ugly012315 Work Inhibition I can work about as well as before 0
  • Page 33 of 50It takes an extra effort to get started at doing somethingI have to push myself very hard to do anythingI cant do any work at all12316 SleepDisturbanceI can sleep as well as usualI dont sleep as well as I used toI wake up 1-2 hours earlier than usual and find it hard to get back tosleepI wake up several hours earlier than I used to and cannot get back tosleep012317 Fatigability I dont get more tired than usualI get tired more easily than I used toI get tired from doing almost anythingI am too tired to do anything012318 Loss of Appetite My appetite is no worse than usualMy appetite is not as good as it used to beMy appetite is much worse nowI have no appetite at all anymore012319 Weight Loss I havent lost much weight, if any, latelyI have lost more than five poundsI have lost more than ten poundsI have lost more than fifteen pounds012320 SomaticPreoccupationI am no more worried about my health than usualI am worried about physical problems such as aches and pains, orupset stomach, or constipationI am very worried about physical problems and its hard to think ofmuch elseI am so worried about my physical problems that I cannot thinkabout anything else012321 Loss of Libido I have not noticed any recent change in my interest in sexI am less interested in sex than I used to beI have almost no interest in sexI have lost interest in sex completely0123
  • Page 34 of 50APPENDIX 4: BECKS DEPRESSION INVENTORY (Vietnamese version used by Vietnam NationalInstitute of Mental Health)Trong bảng này gồm 21 đề mục đƣợc đánh số từ 1 đến 21, ở mỗi đề mục có ghi một số câu phátbiểu. Trong mỗi đề mục hãy chọn ra một câu mô tả gần giống nhất tình trạng mà bạn cảm thấy trong1 tuần trở lại đây, kể cả hôm nay. Khoanh tròn vào con số trƣớc câu phát biểu mà bạn đã chọn. Hãyđừng bỏ sót đề mục nào!1. 0 Tôi không cảm thấy buồn.1 Nhiều lúc tôi cảm thấy buồn.2 Lúc nào tôi cũng cảm thấy buồn.3 Tôi rất buồn hoặc rất bất hạnh đến mức không thể chịu được.2. 0 Tôi không nản lòng về tương lai.1 Tôi cảm thấy nản lòng về tương lai hơn trước.2 Tôi cảm thấy mình chẳng có gì mong đợi ở tương lai cả.3 Tôi cảm thấy tương lai tuyệt vọng và tình hình chỉ có thể tiếp tục xấu đi.3. 0 Tôi không cảm thấy như bị thất bại.1 Tôi thấy mình thất bại nhiều hơn những người khác.2 Nhìn lại cuộc đời, tôi thấy mình đã có quá nhiều thất bại.3 Tôi cảm thấy mình là một người hoàn toàn thất bại.4. 0 Tôi còn thích thú với những điều mà trước đây tôi vẫn thường thích.1 Tôi ít thấy thích những điều mà trước đây tôi vẫn thường ưa thích.2 Tôi còn rất ít thích thú về những điều trước đây tôi vẫn thường thích.3 Tôi không còn chút thích thú nào nữa.5. 0 Tôi hoàn toàn không cảm thấy có tội lỗi gì ghê gớm cả.1 Phần nhiều những việc tôi đã làm tôi đều cảm thấy có tội.2 Phần lớn thời gian tôi cảm thấy mình có tội.3 Lúc nào tôi cũng cảm thấy mình có tội.6. 0 Tôi không cảm thấy đang bị trừng phạt.1 Tôi cảm thấy có lẽ mình đang bị trừng phạt.2 Tôi mong chờ bị trừng phạt.3 Tôi cảm thấy mình đang bị trừng phạt.7. 0 Tôi thấy bản thân mình vẫn như trước kia.1 Tôi không còn tin tưởng vào bản thân.2 Tôi thất vọng với bản thân.3 Tôi ghét bản thân mình.8. 0 Tôi không phê phán hoặc đổ lỗi cho bản thân hơn trước kia.1 Tôi phê phán bản thân mình nhiều hơn trước kia.2 Tôi phê phán bản thân về tất cả những lỗi lầm của mình.3 Tôi đổ lỗi cho bản thân về tất cả mọi điều tồi tệ xảy ra.9. 0 Tôi không có ý nghĩ tự sát.1 Tôi có ý nghĩ tự sát nhưng không thực hiện.2 Tôi muốn tự sát.3 Nếu có cơ hội tôi sẽ tự sát.10. 0 Tôi không khóc nhiều hơn trước kia.1 Tôi hay khóc nhiều hơn trước.2 Tôi thường khóc vì những điều nhỏ nhặt.3 Tôi thấy muốn khóc nhưng không thể khóc được.11. 0 Tôi không dễ bồn chồn và căng thẳng hơn thường lệ.1 Tôi cảm thấy dễ bồn chồn và căng thẳng hơn thường lệ.2 Tôi cảm thấy bồn chồn và căng thẳng đến mức khó có thể ngồi yên được.3 Tôi thấy rất bồn chồn và kích động đến mức phải đi lại liên tục hoặc làm việc gì đó.12. 0 Tôi không mất sự quan tâm đến những người xung quanh hoặc các hoạt động khác.1 Tôi ít quan tâm đến mọi người, mọi việc xung quanh hơn trước.2 Tôi mất hầu hết sự quan tâm đến mọi người, mọi việc xung quanh.3 Tôi không còn quan tâm đến bất kỳ điều gì nữa.13. 0 Tôi quyết định mọi việc cũng tốt như trước.1 Tôi thấy khó quyết định mọi việc hơn trước.2 Tôi thấy khó quyết định mọi việc hơn trước rất nhiều.3 Tôi chẳng còn có thể quyết định được việc gì nữa.14. 0 Tôi không cảm thấy mình là người vô dụng.1 Tôi không cho rằng mình có giá trị và có ích như trước kia.
  • Page 35 of 502 Tôi cảm thấy mình vô dụng hơn so với những người xung quanh.3 Tôi thấy mình là người hoàn toàn vô dụng.15. 0 Tôi thấy mình vẫn tràn đầy sức lực như trước đây.1 Sức lực của tôi kém hơn trước.2 Tôi không đủ sức lực để làm được nhiều việc nữa.3 Tôi không đủ sức lực để làm được bất cứ việc gì nữa.16. 0 Không thấy có chút thay đổi gì trong giấc ngủ của tôi.1a Tôi ngủ hơi nhiều hơn trước.1b Tôi ngủ hơi ít hơn trước.2a Tôi ngủ nhiều hơn trước.2b Tôi ngủ ít hơn trước.3a Tôi ngủ hầu như suốt cả ngày.3b Tôi thức dậy 1-2 giờ sớm hơn trước và không thể ngủ lại được.17. 0 Tôi không dễ cáu kỉnh và bực bội hơn trước.1 Tôi dễ cáu kỉnh và bực bội hơn trước.2 Tôi dễ cáu kỉnh và bực bội hơn trước rất nhiều.3 Lúc nào tôi cũng dễ cáu kỉnh và bực bội.18. 0 Tôi ăn vẫn ngon miệng như trước.1a Tôi ăn kém ngon miệng hơn trước.1b Tôi ăn ngon miệng hơn trước.2a Tôi ăn kém ngon miệng hơn trước rất nhiều.2b Tôi ăn ngon miệng hơn trước rất nhiều.3a Tôi không thấy ngon miệng một chút nào cả.3b Lúc nào tôi cũng thấy thèm ăn.19. 0 Tôi có thể tập trung chú ý tốt như trước.1 Tôi không thể tập trung chú ý được như trước.2 Tôi thấy khó tập trung chú ý lâu được vào bất kỳ điều gì.3 Tôi thấy mình không thể tập trung chú ý được vào bất kỳ điều gì nữa.20. 0 Tôi không mệt mỏi hơn trước.1 Tôi dễ mệt mỏi hơn trước.2 Hầu như làm bất kỳ việc gì tôi cũng thấy mệt mỏi.3 Tôi quá mệt mỏi khi làm bất kỳ việc gì.21. 0 Tôi không thấy có thay đổi gì trong hứng thú tình dục.1 Tôi ít hứng thú với tình dục hơn trước.2 Hiện nay tôi rất ít hứng thú với tình dục.3 Tôi hoàn toàn mất hứng thú tình dục.Xin hãy kiểm tra lại xem còn bỏ sót đề mục nào chưa đánh dấu nữa hay không!
  • Page 36 of 50APPENDIX 5: CENTER FOR EPIDEMIOLOGIC STUDIES—DEPRESSION SCALECircle the number of each statement which best describes how often you felt or behaved this way – DURINGTHE PAST WEEK.During the past week:Rarely ornone of thetime (lessthan 1 day)Some or alittle of thetime (1-2days)Occasionallyor a moderateamount of thetime (3-4 days)Most orall of thetime (5-7days)1) I was bothered by things that usuallydon’t bother me0 1 2 32) I did not feel like eating; my appetite waspoor0 1 2 33) I felt that I could not shake off the blueseven with help from my family and friends0 1 2 34) I felt that I was just as good as otherpeople0 1 2 35) I had trouble keeping my mind on what Iwas doing0 1 2 36) I felt depressed 0 1 2 37) I felt that everything I did was an effort 0 1 2 38) I felt hopeful about the future 0 1 2 39) I thought my life had been a failure 0 1 2 310) I felt fearful 0 1 2 311) My sleep was restless 0 1 2 312) I was happy 0 1 2 313) I talked less than usual 0 1 2 314) I felt lonely 0 1 2 315) People were unfriendly 0 1 2 316) I enjoyed life 0 1 2 317) I had crying spells 0 1 2 318) I felt sad 0 1 2 319) I felt that people disliked me 0 1 2 320) I could not get “going” 0 1 2 3The short form of CESD with 10 item includes the item number: 1, 5, 6, 7, 8, 10, 11,, 12, 14, 20.
  • Page 37 of 50APPENDIX 6: CENTER FOR EPIDEMIOLOGIC STUDIES—DEPRESSION SCALE (VIETNAMESE)(Phuong, 2007)TT Câu phát biểu Hầu hếthoặc cảtuần (5-7ngày)Thƣờngxuyên (3-4 ngày)Thỉnhthoảnghoặc rất ítthời gian(1-2 ngày)Khônghoặc hầunhƣ không(ít hơn 1ngày)1 Bản thấy khó chịu bởi những điều màbình thường không làm cho bạn thấykhó chịu1 2 3 42 Bạn không muốn ăn; bạn không thấyngon miệng1 2 3 43 Bạn không thể thấy vui vẻ, ngay cảkhi gia đình hoặc bạn bè cố gắnggiúp đỡ nhằm làm bạn thấy dễ chịuhơn1 2 3 44 Bạn thấy mình cũng tốt như nhữngngười khác1 2 3 45 Bạn gặp khó khăn để tập trung chú ývào những việc mình đang làm1 2 3 46 Bạn thấy suy sụp và không vui 1 2 3 47 Bạn thấy quá mệt mỏi không thể làmgì được1 2 3 48 Bạn thấy tràn trề hy vọng vào tươnglai1 2 3 49 Bạn nghĩ cuộc đời bạn từ trước đếnnay toàn là thất bại1 2 3 410 Bạn thấy sợ hãi 1 2 3 411 Bạn ngủ không ngon như trước 1 2 3 412 Bạn thấy vui vẻ/hạnh phúc 1 2 3 413 Bạn ít nói hơn bình thường 1 2 3 414 Bạn thấy cô đơn 1 2 3 415 Bạn thấy những người bạn quenkhông than thiện với bạn hoặc họkhông muốn gần gũi bạn1 2 3 416 Tuần vừa qua là một tuần tốt đẹp đốivới bạn1 2 3 417 Trong tuần vừa qua bạn rất muốnkhóc1 2 3 418 Trong tuần vừa qua bạn cảm thấybuồn1 2 3 419 Trong tuần vừa qua, bạn cảm thấymọi người không thích mình1 2 3 420 Trong tuần vừa qua, bạn thấy khó cóthể bắt đầu làm việc1 2 3 4Dạng ngắn gọn của thang đo CESD gồm 10 câu: 1, 5, 6, 7, 8, 10, 11,, 12, 14, 20.
  • Page 38 of 50APPENDIX 7: EDINBURGH POSTNATAL DEPRESSION SCALEAs you are pregnant or have recently had a baby, we would like to know how you are feeling. Please checkthe answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today1. I have been able tolaugh and see the funnyside of things.0 As much as Ialways could1 Not quite somuch now2 Definitely notso much now3 Not at all2. I have looked forwardwith enjoyment tothings0 As much as Iever did1 Rather lessthan I used to2 Definitely lessthan I used to3 Hardly atall3. I have blamed myselfunnecessarily whenthings go wrong3 Yes, most ofthe time2 Yes, some ofthe time1 Not very often 0 No, never4. I have been anxiousfor no good reason0 No, not at all 1 Hardly ever 2 Yes,sometimes3 Yes, veryoften5. I have felt scared orpanicky for no goodreason3 Yes, quite alot2 Yes, sometimes 1 No, not much 0 No, not atall6. Things have beengetting on top of me3 Yes, most ofthe time I haventbeen able to copeat all2 Yes, sometimesI havent beencoping as well asusual1 No, most ofthe time I havecoped quite well0 No, I havebeen coping aswell as ever7. I have been sounhappy that I have haddifficulty sleeping3 Yes, most ofthe time2 Yes, sometimes 1 Not very often 0 No, not atall8. I have felt sad ormiserable3 Yes, most ofthe time2 Yes, quite often 1 Not very often 0 No, not atall9. I have been sounhappy that I havebeen crying.3 Yes, most ofthe time2 Yes, quite often 1 Onlyoccasionally0 No, never10. The thought ofharming myself hasoccurred to me3 Yes, quiteoften2 Sometimes 1 Hardly ever 0 Never
  • Page 39 of 50APPENDIX 8: EDINBURGH POSTNATAL DEPRESSION SCALE (VIETNAMESE VERSION)Vì bạn vừa mới sinh em bé ần đây, chúng tôi muốn hỏi bạn đang cảm thấy như thế nào. Vui lòngđánh dấu vào câu trả lời thể hiện đúng nhất việc bạn cảm thấy như thế nào TRONG VÒNG 7NGÀY VỪA QUA, không chỉ nói về việc bạn cảm như thế nào ngày hôm nay.1. Tôi có thể cười vàcảm nhận những điềuvui vẻ0 Cũng nhưtrước đây1 Ít hơn trướcđây2 Chắc chắn làít hơn trước đây3 Hiếm khi2. Tôi nhìn về tươnglai với niềm hân hoan0 Cũng nhưtrước đây1 Ít hơn trướcđây2 Chắc chắn làít hơn trước đây3 Hiếm khi3. Tôi tự đổ lỗi chomình một cách quámức khi sự việc khôngđúng như mongmuốn?3 Có, hầunhư mọi lúc2 Có, thỉnhthoảng1 Khôngthường xuyên0 Không,không bao giờ4. Tôi có cảm thấy loâu và lo sợ một cáchvô cớ không?0 Không,không bao giờ1 Hiếm khi 2 Có, thỉnhthoảng3 Có, thườngxuyên5. Tôi có cảm thấy sợhãi và hoảng hốt mộtcách vô cớ không?3 Có, khánhiều2 Có, thỉnhthoảng1 Không, hiếmkhi0 Không,không bao giờ6. Tôi có cảm thấycông việc ngập đầukhông?3 Có, hầuhết mọi lúc tôikhông thểđương đầu vớihết tất cả côngviệc2 Có, thỉnhthoảng tôi khônggiải quyết đượcnhư thường lệ1 Không, hầuhết tôi đều giảiquyết tốt0 Không,không bao giờ tôicảm thấy như thế7. Tôi có cảm giácbuồn rầu đến mức khóngủ không?3 Có, hầunhư mọi lúc2 Có, thỉnhthoảng1 Khôngthường xuyên0 Không,không bao giờ8. Tôi có cảm giácbuồn hay khổ sởkhông?3 Có, hầunhư mọi lúc2 Có, thỉnhthoảng1 Khôngthường xuyên0 Không,không bao giờ9. Tôi có cảm giácbuồn rầu đến mứcphải khóc không?3 Có, hầunhư mọi lúc2 Có, thỉnhthoảng1 Khôngthường xuyên0 Không,không bao giờ10. Tôi có cảm nghĩkhông muốn sống nữakhông?3 Có, kháthường2 Thỉnhthoảng1 Hiếm khi 0 Không baogiờ
  • Page 40 of 50APPENDIX 9: STATE TRAIT ANXIETY INVENTORY (VIETNAMESE) (Thai Nguyen Universityof Medicine, 2008, pp. 207-209)Phần I: Gồm 20 câu (từ 1 đến 20) mô tả các trạng thái tâm lý với 4 mức độ:1 - Trạng thái đó không có. 2 - Hình như có. 3 - trạng thái đó có. 4 - Trạng thái đó có rất rõ.TT Trạng thái tâm lýMức độ1 2 3 41 Đang bình tĩnh.    2 Cảm thấy an toàn.    3 Đang căng thẳng.    4 Đang cảm thấy thương tiếc, xót xa...    5 Đang cảm thấy thoải mái..    6 Cảm thấy buồn.    7 Đang lo về những thất bại có thể đến.    8 Cảm thấy mình đã được nghỉ ngơi thoải mái.    9 Đang lo lắng.    10 Cảm thấy dễ chịu trong lòng.    11 Cảm thấy tự tin.    12 Đang bị kích thích.    13 Cảm thấy bồn chồn.    14 Cảm thấy đứng ngồi không yên.    15 Cảm thấy tự nhiên, không bị căng thẳng.    16 Cảm thấy hài lòng.    17 Cảm thấy băn khoăn.    18 Cảm thấy đang bị kích thích, không làm chủ bản thân.    19 Cảm thấy vui vẻ.    20 Cảm thấy dễ chịu.    Phần II: Gồm 20 câu (từ 21 đến 40) gợi ý sự thường xuyên cảm thấy với 4 mức độ:1- Hầu như không khi nào. 2- Đôi lúc. 3- Thường xuyên. 4- Hầu như lúc nào cũng vậy.TT Trạng thái tâm lýMức độ1 2 3 421 Cảm thấy hài lòng.    22 Thường dễ bị mệt mỏi.    23 Dễ khóc.    24 Muốn được hạnh phúc như những người khác.    25 Gặp thất bại do quyết định chậm.    26 Cảm thấy tỉnh táo.    27 Bình thản và tập trung chú ý.    28 Lo lắng về những khó khăn có thể đến.    29 Quá lo nghĩ vì những chuyện lặt vặt.    30 Hoàn toàn hạnh phúc.    31 Quyết định mọi việc thiên về tình cảm.    32 Thiếu tự tin    33 Cảm thấy an toàn.    34 Cố tính đến tình huống khó khăn, phức tạp.    35 Cảm thấy u sầu, buồn chán.    36 Cảm thấy hài lòng.    37 Lo lắng những chuyện tầm phào, nhỏ nhặt    38 Bị thất vọng dằn vặt rất nhiều.    39 Cảm thấy cân bằng và bình tĩnh.    40 Cảm thấy rất lo lắng khi nghĩ tới công việc.    
  • Page 41 of 50APPENDIX 10: BECK ANXIETY INVENTORYSymptomLevel in the past weekNot At All Mildly Moderately Severely1 Numbness or tingling 0 1 2 32 Feeling hot 0 1 2 33 Wobbliness in legs 0 1 2 34 Unable to relax 0 1 2 35 Fear of worst happening 0 1 2 36 Dizzy or lightheaded 0 1 2 37 Heart pounding/racing 0 1 2 38 Unsteady 0 1 2 39 Terrified or afraid 0 1 2 310 Nervous 0 1 2 311 Feeling of choking 0 1 2 312 Hands trembling 0 1 2 313 Shaky / unsteady 0 1 2 314 Fear of losing control 0 1 2 315 Difficulty in breathing 0 1 2 316 Fear of dying 0 1 2 317 Scared 0 1 2 318 Indigestion 0 1 2 319 Faint / lightheaded 0 1 2 320 Face flushed 0 1 2 321 Hot/cold sweats 0 1 2 3
  • Page 42 of 50APPENDIX 11: ZUNG’S SELF-RATING ANXIETY SCALE (Zung, 1971)STT Nội dungNone ora little ofthe timeSome ofthe timeGood partof the timeMost or allof the time1 I feel more nervous and anxious than usual 1 2 3 42 I feel afraid for no reason at all 1 2 3 43 I get upset easily or feel panicky 1 2 3 44 I feel like I’m falling apart and going to pieces 1 2 3 45I feel that everything is all right and nothing badwill happen1 2 3 46 My arms and legs shake ans tremble 1 2 3 47I am bothered by headaches, neck and backpains1 2 3 48 I feel weak and get tired easily 1 2 3 49 I feel calm and can sit still easily 1 2 3 410 I can feel my heart beating fast 1 2 3 411 I am bothered by dizzy spells 1 2 3 412 I have fainting spells or feel like it 1 2 3 413 I can breathe in and out easily 1 2 3 414I get feelings of numbness and tingling in myfingers, toes1 2 3 415 I am bothered by stomachaches or indigestion 1 2 3 416 I have to empty my bladder often 1 2 3 417 My hands are usually dry and warm 1 2 3 418 My face gets hot and blushes 1 2 3 419 I fall asleep easily and get a good night’s rest 1 2 3 420 I have nightmares 1 2 3 4
  • Page 43 of 50APPENDIX 12: ZUNG’S SELF-RATING ANXIETY SCALE (VIETNAMESE) (Vietnam NationalInstitute of Mental Health, 2010c)Dưới đây là 20 câu phát biểu mô tả một số triệu chứng của cơ thể. Ở mỗi câu, hãy chọn một mức độ phùhợp nhất với tình trạng mà anh (chị) cảm thấy trong vòng một tuần vừa qua. Đánh dấu "X" vào mức độ màanh (chị) lựa chọn. Không bỏ sót đề mục nào!STT Nội dungKhôngcóĐôi khiPhần lớnthời gianHầu hết/tấtcả thời gian1 Tôi cảm thấy nóng nảy và lo âu hơn thường lệ 1 2 3 42 Tôi cảm thấy sợ vô cớ 1 2 3 43 Tôi dễ bối rối và cảm thấy hoảng sợ 1 2 3 44 Tôi cảm thấy như bị ngã và vỡ ra từng mảnh 1 2 3 45Tôi cảm thấy mọi thứ đều tốt và không có điềugì xấu sẽ xảy ra1 2 3 46 Tay và chân tôi lắc lư, run lên 1 2 3 47 Tôi đang khó chịu vì đau đầu, đau cổ, đau lưng. 1 2 3 48 Tôi cảm thấy yếu và dễ mệt mỏi. 1 2 3 49Tôi cảm thấy bình tĩnh và có thể ngồi yên mộtcách dễ dàng1 2 3 410 Tôi cảm thấy tim mình đập nhanh 1 2 3 411 Tôi đang khó chịu vì cơn hoa mắt chóng mặt 1 2 3 412 Tôi bị ngất và có lúc cảm thấy gần như thế 1 2 3 413 Tôi có thể thở ra, hít vào một cách dễ dàng 1 2 3 414Tôi cảm thấy tê buốt, như có kiến bò ở đầungón tay, ngón chân1 2 3 415 Tôi đang khó chịu vì đau dạ dày và đầy bụng. 1 2 3 416 Tôi luôn cần phải đi đái 1 2 3 417 Bàn tay tôi thường khô và ấm 1 2 3 418 Mặt tôi thường nóng và đỏ 1 2 3 419 Tôi ngủ dễ dàng và luôn có một giấc ngủ tốt 1 2 3 420 Tôi thường có ác mộng 1 2 3 4
  • Page 44 of 50APPENDIX 13: ANXIETY SCALE (Nguyen, 2006) (ENGLISH AND VIETNAMESE)Statement Never Sometimes Often1. When I feel frightened, it is hard to breadth or I sweata lot1  2  3 2. I worry about sleeping alone 1  2  3 3. I worry about being as good as other kids 1  2  3 4. I get really frightened for no reason at all 1  2  3 5. I worry that something bad will happen to me or to myfamily1  2  3 6. I worry about how well I do things 1  2  3 7. I feel nervous with people I don’t know well 1  2  3 8. I cry easily 1  2  3 9. I startle easily 1  2  3 10. I get scared if I sleep away from home 1  2  3 11. I am afraid to be alone in the house 1  2  3 12. I have nightmares about something bad happening tomyself or to my family1  2  3 13. I have difficulty falling asleep 1  2  3 Phát biểuChƣa baogiờThỉnhthoảngThƣờngxuyên1. Khi bạn sợ hãi, bạn thấy khó thở hoặc toát mồ hôinhiều1  2  3 2. Bạn thấy lo lắng khi phải ngủ một mình 1  2  3 3. Bạn thấy lo lắng sợ mình không được như các bạnkhác1  2  3 4. Bạn thấy sợ mà không có nguyên do gì 1  2  3 5. Bạn lo sợ chuyện gì xấu sẽ xảy ra với bạn hoạc vớigia đình bạn1  2  3 6. Bạn thấy lo không biết có làm tốt được mọi thứkhông1  2  3 7. Bạn thấy lo lắng khi phải tiếp xúc với người mà bạnkhông quen biết1  2  3 8. Bạn rất dễ khóc 1  2  3 9. Bạn rất dễ giật mình 1  2  3 10. Bạn thấy sợ khi phải ngủ xa nhà 1  2  3 11. Bạn thấy sợ khi ở một mình trong nhà 1  2  3 12. Bạn có những cơn ác mộng về điều gì xấu xảy ra vớibạn hoặc gia đình bạn1  2  3 13. Bạn thấy khó ngủ mỗi khi lên giường 1  2  3 
  • Page 45 of 50APPENDIX 14: A SHORT FORM OF YRBS USED IN VIETNAM BY (Nguyen, 2006)Below are statements about some events children may experience. For each item, please tick (x) in only onebox that is true to youYES NO1. Past 12 months, ever felt so sad or hopeless almost every day for the twoweeks or more that stopped doing some usual activities2. Past 12 months, ever seriously considered attempting suicide3. Past 12 months, ever made a plan about would attempt suicide4. Past 30 days, had ever smoked cigarettes5. Past 30 days, had one or more drink of alcohol6. Have ever been drunk (during lifetime)7. Ever accidentally injured while drunk (like falling down, hurt in fight, falling pff abicycle/motorbike)8. Past 30 days, have gone without eating for 24 hours or more to lose weight orto keep from gaining weight9. Past 30 days, had carried a weapon such as knife or club10. Past 12 months, have been threatened or injured by somebody with a weaponon school property11. Past 12 months, have been involved in fighting
  • Page 46 of 50APPENDIX 15: EDUCATIONAL STRESS SCALE FOR ADOLESCENTS (JIANDONG SUN ET AL,2011)Following statements are about your feelings and attitude toward your academic achievement andstudy. Please circle the number that best represents your attitude toward your academicachievement and study.StronglydisagreeDisagree Neitheragree nordisagreeAgree StronglyagreeES1I am very dissatisfied with myacademic grades1 2 3 4 5ES2I feel that there is too much schoolwork1 2 3 4 5ES3 I feel there is too much homework 1 2 3 4 5ES4Future education and employmentbring me a lot of academic pressure1 2 3 4 5ES5My parents care about my academicgrades too much which brings me alot of pressure1 2 3 4 5ES6I feel a lot of pressure in my dailystudying1 2 3 4 5ES7I feel that there are too many tests/exams in the school1 2 3 4 5ES8My academic grades are veryimportant to my future and even candetermine my whole life1 2 3 4 5ES9I feel that I have disappointed myparents when my test/exam resultsare poor1 2 3 4 5ES10I feel that I have disappointed myteacher when my test/exam resultsare not ideal1 2 3 4 5ES11There is too much competition amongclassmates which brings me a lot ofacademic pressure1 2 3 4 5ES12I always have a lack of confidencewith my academic scores1 2 3 4 5ES13It is very difficult to concentrate duringclasses1 2 3 4 5ES14I feel stressed when I do not live up tomy own standards.1 2 3 4 5ES15When I fail to live up to my ownexpectations, I feel I am not goodenough.1 2 3 4 5ES16I usually cannot sleep and worry whenI cannot meet the goals I set formyself.1 2 3 4 5
  • Page 47 of 50APPENDIX 16: EDUCATIONAL STRESS SCALE FOR ADOLESCENTS (VIETNAMESE VERSIONBY TRUC ET AL, 2011)Những câu dƣới đây nói về cảm nhận và thái độ của bạn về thành tích học tập và việc học của bạn.Bạn hãy khoanh tròn con số thể hiện đúng nhất thái độ của bạn về thành tích học tập và việc học củabạn.Hoàn toànkhông đồng ýKhôngđồng ýKhôngbiếtĐồng ýHoàntoànđồng ýES1Tôi cảm thấy rất thất vọng về điểmhọc tập của tôi1 2 3 4 5ES2Tôi cảm thấy có quá nhiều bài ởtrường1 2 3 4 5ES3Tôi có quá nhiều bài tập về nhà đểlàm1 2 3 4 5ES4Nghĩ về việc học trong tương laitạo nhiều áp lực học tập đối với tôi1 2 3 4 5ES5Việc ba mẹ quan tâm quá nhiềuđến việc học của tôi tạo nhiều áplực đối với tôi1 2 3 4 5ES6Tôi cảm thấy việc học hàng ngàycó nhiều áp lực1 2 3 4 5ES7Có quá nhiều bài kiểm tra và kì thitrong trường1 2 3 4 5ES8Thành tích học tập của tôi là rấtquan trọng cho tương lai tôi vàthậm chí nó quyết định toàn bộcuộc đời của tôi1 2 3 4 5ES9Tôi cảm thấy tôi đã làm thất vọngba mẹ khi kết quả bài thi/kiểm tracủa tôi thấp1 2 3 4 5ES10Tôi cảm thấy tôi đã làm thất vọngthầy cô khi kết quả bài thi/kiểm tracủa tôi không hoàn hảo (lý tưởng)1 2 3 4 5ES11Việc có quá nhiều cạnh tranh trongviệc học với các bạn trong lớpmang lại nhiều áp lực học cho tôi1 2 3 4 5ES12Tôi luôn thiếu tự tin với điểm sốhọc tập của tôi1 2 3 4 5ES13 Tôi rất khó tập trung trong giờ học 1 2 3 4 5ES14Tôi thấy căng thẳng khi tôi khôngsống theo tiêu chuẩn của chínhmình1 2 3 4 5ES15Khi tôi không đạt được kì vọngmình đặt ra, tôi thấy mình không đủgiỏi1 2 3 4 5ES16Tôi thường không thể ngủ và thấylo lắng khi tôi không thể đạt đượcmục tiêu tôi đặt ra cho chính mình1 2 3 4 5
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  • Mã số người tham gia phỏng vấn: [ ][ ] [ ][ ] [ ][ ]Bộ Câu Hỏi Quốc Tế Về Những Trải Nghiệm Bất Lợi Thời Thơ Ấu (ACE-IQ)Phần B: Bộ Câu HỏiB1.1BỘ CÂU HỎI QUỐC TỂ VỀ NHỮNG TRẢI NGHIỆM BẤT LỢI THỜI THƠ ẤU(ACE-IQ)0 THÔNG TIN DÂN SỐ XÃ HỘI0.1[C1]Giới tính (ghi nhận nam/nữ khi quan sát) NamNữ0.2[C2]Bạn sinh vào ngày tháng năm nào? Ngày [ ][ ] Tháng [ ][ ] Năm [ ][ ][ ][ ]Nếu không biết (chuyển sang C3)0.3[C3]Năm nay bạn bao nhiêu tuổi? [ ][ ]0.4[C4]Hoàn cảnh của bạn là gì ? [chèn vào nhómdân tộc thích hợp / nhóm chủng tộc / nhómvăn hóa / khác][Xác định tùy vào từng địa phương][Xác định tùy vào từng địa phương][Xác định tùy vào từng địa phương]Từ chối0.5[C5]Trình độ học vấn cao nhất mà bạn đã hoàn tấtlà gì?Chưa bao giờ đi họcDưới tiểu họcTiểu học (cấp 1)Trung học cơ sở/Trung học phổ thong(cấp 2&3)Trung học kỹ thuật/Đại họcSau đại họcTừ chối trả lời0.6[C6]Những nghề nghiệp nào sau đây mô tả chínhxác nhất công việc chính của bạn trong 12tháng vừa qua?Nhân viên nhà nướcNhân viên phi chính phủTự làm chủCông việc không được trả lươngSinh viênNội trợNghỉ hưuThất nghiệp (vẫn còn khả năng làm việc)Thất nghiệp (không còn khả năng làm việc)Từ chối trả lời0.7[C7]Tình trạng hôn nhân của bạn là gì? Đang sông chung với nhau (chuyển sang câuQ.M2)Sống chung như vợ chồngLy hôn hoặc ly thânĐộc thânGóa (chuyển sang câu Q.M2)KhácTừ chối trả lời1 HÔN NHÂN1.1[M1]Bạn đã từng kết hôn chưa? CóKhông (chuyển sang câu Q.M5)Từ chối trả lời1.2[M2]Bạn kết hôn lần đầu tiên lúc bạn bao nhiêutuổi?Tuổi [ ][ ]Từ chối trả lời1.3[M3]Vào thời điểm bạn kết hôn lần đầu tiên, tự bảnthân bạn đã chọn người chồng của bạn phảikhông?Có (chuyển sang câu Q.M5)KhôngKhông biết/không chắc chắnTừ chối trả lời
  • Mã số người tham gia phỏng vấn: [ ][ ] [ ][ ] [ ][ ]Bộ Câu Hỏi Quốc Tế Về Những Trải Nghiệm Bất Lợi Thời Thơ Ấu (ACE-IQ)Phần B: Bộ Câu HỏiB1.21.4[M4]Vào thời điểm bạn kết hôn lần đầu tiên, nếu tựbản thân bạn đã không chọn người chồng đó,thì bạn có đồng thuận với lựa chọn đó?CóKhôngTừ chối trả lời1.5[M5]Nếu bạn là một người cha, hoặc người mẹ,bạn sinh đứa con đầu tiên vào năm bao nhiêutuổi?Tuổi [ ][ ]Không phù hợpTừ chối trả lời2 MỐI QUAN HỆ VỚI BA MẸ/NGƯỜI BẢO HỘTrong khoảng thời gian bạn trưởng thành đến năm 18 tuổi....,2.1[P1]Cha mẹ/người bảo hộ của bạn có hiểu nhữngvấn đề mà bạn đang gặp phải và những lolắng không?Luôn luônThường xuyênThỉnh thoảngHiếm khiKhông bao giờTừ chối trả lời2.2[P2]Cha mẹ/ người bảo hộ của bạn có thật sự biếtbạn đang làm gì lúc rãnh rỗi khi bạn không đihọc hoặc không đi làm không?Luôn luônThường xuyênThỉnh thoảngHiếm khiKhông bao giờTừ chối trả lời33.1[P3]Bao nhiêu lần cha mẹ/người bảo hộ bạn đãkhông cho bạn đầy đủ thức ăn khi họ có thểlàm được điều đó dễ dàng?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời3.2[P4]Cha mẹ/người bảo hộ bạn có quá say rượuhoặc say thuốc đến nỗi không chăm sóc bạnkhông?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời3.3[P5]Bao nhiêu lần cha mẹ/người bảo hộ bạn đãkhông cho bạn đến trường ngay cả khi trườnghọc có sẵn?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời4 MÔI TRƯỜNG GIA ĐÌNHTrong khoảng thời gian bạn trưởng thành đến năm 18 tuổi....,4.1[F1]Bạn có sống với người nào trong gia đình cóvấn đề nghiện rượu, hoặc lạm dụng thuốc,hoặc dùng sai toa thuốc không?CóKhôngTừ chối trả lời4.2[F2]Bạn có sống với người nào trong gia đình bịtrầm cảm, bệnh tâm thần hoặc có ý định tự tửkhông?CóKhôngTừ chối trả lời4.3[F3]Bạn có sống với người nào trong gia đình đã bịgiam trong nhà giam hoặc đi tù không?CóKhôngTừ chối trả lời4.4[F4]Cha mẹ bạn có từng ly hôn hoặc ly thânkhông?CóKhông
  • Mã số người tham gia phỏng vấn: [ ][ ] [ ][ ] [ ][ ]Bộ Câu Hỏi Quốc Tế Về Những Trải Nghiệm Bất Lợi Thời Thơ Ấu (ACE-IQ)Phần B: Bộ Câu HỏiB1.3Không phù hợpTừ chối trả lời4.5[F5]Cha mẹ hoặc người bảo hộ bạn đã chết phảikhông?CóKhôngKhông biết/không chắc chắnTừ chối trả lờiNhững câu hỏi kế tiếp hỏi về những việc bạn nghe được hoặc thấy được trong GIA ĐÌNH BẠN.Những việc này có thể xảy đến với những thành viên khác trong gia đình, không nhất thiết làxảy đến với bạn.Trong khoảng thời gian bạn trưởng thành đến năm 18 tuổi....,4.6[F6]Bạn có thấy hoặc nghe thấy cha/mẹ/thành viênkhác trong gia đình bạn, bị la hét, thét hoặcchửi rủa, bị sỉ nhục hoặc bị làm bẽ mặt không?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời4.7[F7]Bạn có thấy hoặc nghe thấy cha/mẹ/thành viênkhác trong gia đình bạn bị tát, đá, đấm hoặc bịđập không?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời4.8[F8]Bạn có thấy hoặc nghe thấy cha/mẹ/thành viênkhác trong gia đình bạn, bị đánh hoặc bị cứabằng một vật như cây gậy, chai, dùi cui, dao,roi... không?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lờiNhững câu hỏi kế tiếp hỏi về những việc BẠN đã trải qua.Trong khoảng thời gian bạn trưởng thành đến năm 18 tuổi....,55.1[A1]Cha/mẹ hoặc người bảo hộ, hoặc những thànhviên khác có la hét, thét lên hoặc chửi rủa, sỉnhục bạn hoặc làm bạn bẽ mặt không?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời5.2[A2]Cha/mẹ hoặc người bảo hộ, hoặc những thànhviên khác có đe dọa từ bỏ bạn hoặc đuổi bạnra khỏi nhà không?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời5.3[A3]Cha/mẹ hoặc người bảo hộ, hoặc những thànhviên khác có tát, đá, đấm hoặc đập bạnkhông?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời5.4[A4]Cha/mẹ hoặc người bảo hộ, hoặc những thànhviên khác có đánh hoặc cứa bạn bằng một vậtnhư cây gậy, chai, dùi cui, dao, roi... không?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời
  • Mã số người tham gia phỏng vấn: [ ][ ] [ ][ ] [ ][ ]Bộ Câu Hỏi Quốc Tế Về Những Trải Nghiệm Bất Lợi Thời Thơ Ấu (ACE-IQ)Phần B: Bộ Câu HỏiB1.45.5[A5]Có người nào sờ hoặc vuốt ve bạn một cáchkích dục khi bạn hoàn toàn không muốnkhông?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời5.6[A6]Có người nào khiến bạn phải sờ hoặc chạmvào cơ thể của họ theo cách gợi cảm/kích dụckhi bạn hoàn toàn không muốn không?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời5.7[A7]Có người nào cố gắng quan hệ với bạn quađường miệng, hậu môn hoặc âm đạo khi bạnhoàn toàn không muốn không?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời5.8[A8]Có người nào thật sự quan hệ với bạn quađường miệng, hậu môn hoặc âm đạo khi bạnhoàn toàn không muốn không?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời6 BẠO LỰC CÙNG LỨA TUỔINhững câu hỏi kế tiếp hỏi về việc bạn BỊ BẮT NẠT trong suốt quá trình trưởng thành.Bắt nạt là khi một người trẻ hoặc một nhóm người trẻ nói hoặc làm những việc khôngtốt hoặc không làm hài lòng đối với một người trẻ khác. Bắt nạt cũng có thể là khi mộtngười trẻ bị trêu ghẹo nhiều và người đó không hài long, hoặc khi một người trẻ bị côlập có mục đích. Bắt nạt không phải là khi 2 người trẻ có cùng sức khỏe tranh cãi hoặcđánh nhau, hoặc khi trêu ghẹo theo cách thân thiện hoặc vui vẻ.Trước khi bạn bước đến tuổi 18 tuổi...,6.1[V1]Bao nhiêu lần bạn bị bắt nạt? Nhiều lầnVài lầnMột lầnKhông bao giờ (chuyển sang câu Q.V3)Từ chối trả lời6.2[V2]Bạn thường xuyên bị bắt nạt theo cách nào? Tôi bị đánh, đá, đẩy, xô một cách thô bạo,hoặc bị nhốt bên trong phòngTôi bị làm trò vui bởi vì chủng tộc, quốc tịchhoặc màu da của tôiTôi bị làm trò vui bởi vì tôn giáo của tôiTôi bị làm trò vui với những cử chỉ, lời chọcghẹo, hoặc nói đùa kích dụcTôi bị đuổi khỏi những hoạt động một cáchcó chủ ý hoặc bị phớt lờ hoàn toànTôi bị làm trò vui bởi vì cơ thể và khuôn mặtcủa tôiTôi bị bắt nạt theo một số cách khácTừ chối trả lờiCâu hỏi kế tiếp này hỏi về những lúc ĐÁNH NHAU. Đánh nhau là khi 2 học sinh có cùng sứcmạnh hoặc quyền lực đánh nhau.
  • Mã số người tham gia phỏng vấn: [ ][ ] [ ][ ] [ ][ ]Bộ Câu Hỏi Quốc Tế Về Những Trải Nghiệm Bất Lợi Thời Thơ Ấu (ACE-IQ)Phần B: Bộ Câu HỏiB1.5Trước khi bạn bước đến tuổi 18 tuổi...,6.3[V3]Bao nhiêu lần bạn đánh nhau với người khác? Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời7 CHỨNG KIẾN BẠO LỰC Ở CỘNG ĐỒNGNhững câu hỏi kế tiếp hỏi về mức độ thường xuyên, khi bạn là một đứa trẻ, BẠN có thấyhoặc nghe nói ở HÀNG XÓM HOẶC CỘNG ĐỒNG (không phải trong gia đình bạn,trên tivi, phim hoặc radio)Trong khoảng thời gian bạn trưởng thành đến năm 18 tuổi....,7.1[V4]Bạn có thấy hoặc nghe thấy người nào bịđánh ở ngoài đời không?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời7.2[V5]Bạn có thấy hoặc nghe thấy người nào bị đâmhoặc bị bắn ở ngoài đời không?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời7.3[V6]Bạn có thấy hoặc nghe thấy người nào bị đedọa bằng dao hoặc súng ở ngoài đời không?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời8 TIẾP XÚC VỚI BẠO LỰC DO CHIẾN TRANH CHÍNH TRỊ / BẠO LỰC TẬP THỂNhững câu hỏi kế tiếp hỏi về việc BẠN đã hoặc đã không trải qua những sự kiện sau đâykhi bạn là một đứa trẻ. Những sự kiện này bao gồm bạo lực tập thể ví dụ như: chiếntranh, khủng bố, mâu thuẫn chính trị, diệt chủng, đàn áp, làm cho biến mất, tra tấn,hoặc tội ác bạo lực có tổ chức như chiến tranh cướp bóc...Trong khoảng thời gian bạn trưởng thành đến năm 18 tuổi....,8.1[V7]Bạn có bị ép buộc đi hoặc sống ở mộtnơi khác do bất cứ sự kiện nêu trênkhông?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời8.2[V8]Bạn có trải qua chuyện nhà bạn bị pháhoại một cách chủ ý do bất cứ sự kiệnnêu trên không?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời8.3[V9]Bạn có bị đánh bởi lính, cảnh sát, quânđội, hoặc côn đồ không?Nhiều lầnVài lầnMột lầnKhông bao giờTừ chối trả lời8.4 Thành viên gia đình bạn hoặc bạn của Nhiều lần
  • Mã số người tham gia phỏng vấn: [ ][ ] [ ][ ] [ ][ ]Bộ Câu Hỏi Quốc Tế Về Những Trải Nghiệm Bất Lợi Thời Thơ Ấu (ACE-IQ)Phần B: Bộ Câu HỏiB1.6[V10) bạn có bị giết bởi lính, cảnh sát, quânđội hoặc côn đồ không?Vài lầnMột lầnKhông bao giờTừ chối trả lời
  • Journal of Psychoeducational Assessment29(6) 534­–546© 2011 SAGE PublicationsReprints and permission: 10.1177/0734282910394976http://jpa.sagepub.comEducational Stress Scalefor Adolescents:Development,Validity,and Reliability WithChinese StudentsJiandong Sun,1Michael P. Dunne,1Xiang-yu Hou,1and Ai-qiang Xu2AbstractThis article describes the development and initial validation of a new instrument to measureacademic stress—the Educational Stress Scale forAdolescents (ESSA).A series of cross-sectionalquestionnaire surveys were conducted with more than 2,000 Chinese adolescents to examinethe psychometric properties. The final 16-item ESSA contains five latent variables: Pressurefrom study,Workload,Worry about grades, Self-expectation, and Despondency, which togetherexplain 64% of the total item variance. Scale scores showed adequate internal consistency,2-week test–retest reliability, and satisfactory concurrent validity.A confirmatory factor analysissuggested the proposed factor model fits well in a different sample. For researchers who have aparticular interest in academic stress among adolescents, the ESSA promises to be a useful tool.KeywordsESSA, validity, reliability, academic stress, Chinese adolescentsAcademic learning is among the most important sources of stress among young students world-wide and appears to be quite severe in Asian countries (Brown, Teufel, Birch, & Kancherla,2006; Christie & MacMullin, 1998; Dodds & Lin, 1992; Gallagher & Millar, 1996; Huan, See,Ang, & Har, 2008; Tang & Westwood, 2007). Asian students usually have high academic burden(Lee & Larson, 2000), low satisfaction regarding their academic performance, and high expecta-tions (Crystal et al., 1994) and may suffer more academic stress (Ang & Huan, 2006a; Ang,Huan, & Braman, 2007) than their counterparts in English speaking countries. Academic stressis a significant contributor to a variety of mental and behavioral disorders, such as depression,anxiety, and suicidal behavior (Ang & Huan, 2006b; Bjorkman, 2007).1Queensland University of Technology, Kelvin Grove,Australia2Shandong Provincial Centre for Disease Control and Prevention, Jinan, ChinaCorresponding Author:Michael P. Dunne, School of Public Health, Queensland University of Technology,Victoria Park Road, Kelvin Grove,QLD 4059,AustraliaEmail:
  • Sun et al. 535In China, there has been a growing recognition of academic burden and its health impact amongstudents as a public health and educational concern. A national survey conducted with 5,040 ado-lescents and 6,552 parents by the All-China Women’s Federation (2008) reported that nearly half(49.1%) of the students in secondary schools spend at least 2 hr per day for homework assigned bytheir teachers. Another national survey (China Youth Social Service Center, 2008) found that mostchildren and adolescents (66.7%) considered academic pressure as the biggest stress in their lives.Academic-related factors, such as underachievement, pressure from transitional examinations, andstudy workload are associated with poor mental health among Chinese adolescents (Li & Zhang,2008; Liu & Tein, 2005; Zhang, Tao, & Zeng, 2001). High academic pressure may also lead tophysical violence and many developmental problems (Lin & Chen, 1995).Anumber of self-report instruments have been developed to assess the level of academic stress andassociations with health problems among adolescents. These include the Academic Stress Question-naire (Abouserie, 1994), Student Stress Inventory (Zeidner, 1992), Academic Stress Scale (Kohn &Frazer, 1986), LakaevAcademic Stress Response Scale (Lakaev, 2009), Student-life Stress Inventory(Gadzella, 2001), High School Stressor Scale (HSSS; Burnett & Fanshawe, 1997),Academic Expec-tation Stress Inventory (AESI;Ang & Huan, 2006a), and Survey ofAcademic Stress (SAS; Bjorkman,2007). Most of these scales were designed and used to measure academic stress among college oruniversity students, and only three have been used in surveys with secondary school students.All butthe AESI (Ang & Huan, 2006a, 2006b) were developed and validated in Western countries.Among the three instruments used in secondary school settings, the HSSS (Burnett &Fanshawe, 1997) was developed with a sample of Australian students (Year 8 through 12). Itincludes 35 items and 9 latent variables. One problem for this scale is the psychometric proper-ties are less than satisfactory. For example, the Goodness-of-Fit Index (GFI; .85) and AdjustedGoodness-of-Fit Index (AGFI; .82) based on the confirmatory factor analysis (CFA) are belowthe threshold of an adequate fit (.90). The internal consistency for some factors was well belowthe threshold of a sufficient reliability (.70) for a new scale (Hinkin, 1998). The SAS (Bjorkman,2007) is a 23-item scale developed with a U.S. sample of junior high school students. However,its factor structure is problematic. For example, one of the four factors contains only two itemsthat is less than the recommended minimum number of 3 (Costello & Osborne, 2005).The AESI (Ang & Huan, 2006a) is the only one among the reviewed instruments that has beenused inAsian countries. It was developed with Singapore students to measure the level of stress aris-ing from academic expectations of both the students and significant others. Its psychometric profilehas been well established, and cross-cultural validity has also been tested with both Chinese andHispanic students (Ang & Huan, 2006a, 2006b). However, the AESI authors acknowledged that thescale was limited to measurement of stress because of academic expectations. The purpose of thepresent study was to extend the range of factors that contribute to the construct of educational stress.In Chinese context, apart from high expectations, heavy burden of schoolwork and home-work, negative attitudes toward learning, such as dissatisfaction with grades, loss of interest, anddifficulties in studying may also be important sources of pressure and stress among students (Lin& Chen, 1995; Lu, 2008). Thus, a more comprehensive tool seems necessary to study the natureand health effects of educational stress. Extensive review of both English and Chinese literaturefound no instrument that measures the multifactorial nature of academic stress among highschool students in Asian countries.MethodsDesignThis study consisted of three cross-sectional questionnaire surveys with convenience sam-ples of students (Grades 7-12) from six secondary schools in three sites (the capital city, one
  • 536 Journal of Psychoeducational Assessment 29(6)county city, and one rural town) in Shandong Province, China. These surveys were conductedin September and October 2009. The objective of the first survey was to explore the factorstructure, internal consistency, concurrent validity, and predictive validity of the draft Edu-cational Stress Scale for Adolescent (ESSA). The second survey was to assess the test–retestreliability. The third survey was to evaluate the robustness of the factor structure establishedin the first survey.ParticipantsScale development sample. The first sample contained 364 Grade 8 and 11 students. Data anal-ysis was conducted with 347 students with a response rate of 95.3%. Of them, 44.8% werefemale and all were from the Han Chinese ethnic group. The age of the sample ranged from 12to 18 (M = 15.37, SD = 1.69). Students from urban and rural families accounted for 43.2% and56.8% of the sample, respectively.Test–retest reliability sample. Two weeks later, a subset of the first sample (two classes, N = 148)participated in a second survey with the same questionnaires. Data analysis on test–retest reli-ability was done with 135 (91.2%) respondents. The demographic characters were similar to thefirst sample.CFA sample. A total of 1,740 eligible participants (Grades 7 through 12) from 36 classeswere invited to participate in the third survey. Complete data were obtained from 1,670 (95.8%)students and were included in the analysis. Of them, 44.6% were female and almost all (99.3%,1,659/1,670) were ethnically Han Chinese. The age of the respondents ranged from 11 to 20(M = 15.44, SD = 1.85). Urban and rural students accounted for 42.2% and 57.8% of thesample, respectively.MeasuresEducational stress. The preliminary version of the ESSA was used in the first two surveys.It contained 30 items derived from extensive review of both the English and Chinese litera-ture and discussions with professionals in both public health and education in China. Sixdomains of stress consisting of five items each were predefined, including attitudes towardstudy and grades (such as “I am very dissatisfied with my academic grades”), perceived pres-sure (such as “I feel a lot of pressure in my daily studying”), perceived burden (such as “I feelthat there is too much schoolwork”), expectations from others (such as “I feel that I havedisappointed my parents when my test/exam results are poor”), and self-expectation (such as“I feel stressed when I do not live up to my own standards”). Seven items were adapted fromthe AESI (Ang & Huan, 2006a) to form the last two dimensions. The response format used a5-point Likert-type scale ranging from 1 = strongly disagree to 5 = strongly agree with ahigher score indicating greater stress.Items were initially created in English or adopted from other English scales. The Chinese ver-sion was then generated using the backward translation technique. More specifically, two bilin-gual persons with Chinese background based at the Queensland University of Technology (QUT)independently translated the items into Chinese. The two Chinese copies were then sent toanother bilingual professional based at Shandong University, China for review and translationinto English. The back-translated scale was reviewed by an English native speaker at QUT toconfirm its equivalence with the original. Revisions were made in the Chinese translation basedon comments from the final reviewer.After pilot testing, the scale was revised and a final 16-item version was used in the mainsurvey. In the final scale, five items (Items 9, 10, 14, 15, 16; Table 1) were adapted from theAESI(Ang & Huan, 2006a) with minor wording changes.
  • Sun et al. 537Academic expectation stress. The original (English) AESI (Ang & Huan, 2006a) was translatedinto Chinese following the same procedure for the ESSA and was used in this study. This nine-item scale has two subscales, Expectations of Parents/Teachers (five items) and Expectations ofTable 1. Rotated Factor Loadings and Communalities (h2) for the ESSA in the EFA (N = 347) and FactorLoadings in the CFA (N = 1,670)EFACFAFactor loadingsFactor loadingsh21 2 3 4 5  6. I feel a lot of pressure in my dailystudying.77a-.01 -.02 -.09 .03 .56 .8011.  There is too much competitionamong classmates that brings me alot of academic pressure.76a.06 .03 .05 -.21 .51 .66  4. Future education and employmentbring me a lot of academic pressure.68a-.09 -.02 .04 .08 .51 .72  5. My parents care about my academicgrades too much that brings me a lotof pressure.54a.13 .04 -.08 .14 .36 .64  3.  I feel there is too much homework .06 .81a-.08 .06 -.07 .68 .70  2. I feel that there is too muchschoolwork-.11 .70a.10 -.07 .15 .52 .68  7. I feel that there are too many tests/exams in the school.07 .59a.04 .03 -.02 .39 .6910. I feel that I have disappointed myteacher when my test/exam resultsare not ideal-.10 .09 .93a-.09 -.10 .74 .67  9. I feel that I have disappointed myparents when my test/exam resultsare poor.15 .01 .59a.15 .04 .56 .85  8. Academic grade is very important tomy future and even can determine mywhole life.13 -.13 .53a.12 .14 .37 .5214. I feel stressed when I do not live upto my own standards-.02 .08 -.10 .84a.01 .66 .7115. When I fail to live up to my ownexpectations, I feel I am not goodenough-.01 .01 .05 .59a-.06 .35 .5616. I usually cannot sleep because ofworry when I cannot meet the goals Iset for myself-.04 -.08 .10 .52a.08 .32 .5812. I always lack confidence with myacademic scores.04 .03 -.03 -.04 .68a.49 .52  1. I am very dissatisfied with myacademic grades-.15 -.01 .04 .05 .66a.37 .6813. It is very difficult for me toconcentrate during classes.17 .08 -.08 .00 .51a.39 .67Note: Factors loadings in the CFA are the standardized regression weights for each item with the correspondingfactor. ESSA = Educational Stress Scale for Adolescents; EFA = exploratory factor analysis; CFA = confirmatory factoranalysis; Factor 1 = Pressure from study; Factor 2 = Workload; Factor 3 = Worry about grades;Factor 4 = Self-expectation; Factor 5 = Despondency; h2= Communalities.a. Factor loadings with values of 0.5 or greater in the EFA are shown in bold.
  • 538 Journal of Psychoeducational Assessment 29(6)Self (four items). Respondents rated each statement on a 5-point Likert-type scale ranging from1 = never true to 5 = almost always true. The possible total score ranges from 9 to 45, with higherscores indicating greater stress. It gained good internal consistency (Cronbach’s a = .89 for thetotal scale, .84-.85 for two factors) in the original study (Ang & Huan, 2006a).Depressive symptoms. The Chinese version of Centre for Epidemiological Studies–DepressionScale (CES-D; Liu, 1999; Radloff, 1977) is a 20-item self-report instrument for depressivesymptoms. Items were rated using a 4-point scale from rarely or none of the time (less than 1 day)to most or all of the time (5 to 7 days) during the past week and were scored either 0 to 3 or 3 to 0,with a total range of 0 to 60, where higher scores indicate greater frequency and number of symp-toms. It has four separate factors: depressive affect, somatic symptoms, positive effect, and inter-personal relations. The CES-D has good internal consistency with alphas of .85 for the generalpopulation and .90 for a psychiatric population (Radloff, 1977).Suicidal thoughts. Suicidal thoughts were measured using one question “In the past 12 months,have you ever seriously considered attempting suicide?” adopted from the Youth Risk BehaviorSurvey Questionnaire (Eaton et al., 2008). Students who responded “yes” to this question weredefined as having suicidal thoughts. This question has been widely used in the United States(Brener et al., 2002; Eaton et al., 2008), China (Chen, Dunne, & Han, 2006), and elsewhere.Academic grades. Participants were asked to rank their average grades during the past 12months into one of the five categories: very poor, poor, middle, good, and very good. In dataanalysis, the first two and last two groups were combined as very poor/poor and good/very good,respectively, resulting in three categories coded from 1 to 3.ProcedureAll surveys were conducted in schools during self-study sessions. A brief introduction was givenby the investigator followed by the distribution of assent forms and information sheets. The sur-vey questionnaire was then administered to the students who signed assent forms. On average, ittook 30 min for the students to complete the questionnaires. For the test–retest survey, a techniquereported by Brener and colleagues (Brener, Collins, Kann, Warren, & Williams, 1995; Brener et al.,2002) was followed to assure anonymity and obtain matching data from participants.Data AnalysesAnalyses were conducted using SPSS for Windows 17.0 (SPSS, Chicago, IL) andAmos 7.0 (SPSS,Chicago, IL). All statistical tests were two-sided and significance level was defined as a = .05.Ethics ApprovalThis project obtained ethics approval from the University Human Research Ethics Committee ofQUT and the Preventive Medicine Ethics Committee of Shandong Provincial Centre for DiseaseControl and Prevention (CDC). Participation was entirely voluntary and anonymous. Before the datacollection, a written approval was given by the principal/vice principal of each participating schooland a standard assent was gained from each student. Passive consent was also obtained from parents.ResultsExploratory Factor Analysis (EFA)The factor structure of the preliminary 30-item ESSA was identified using EFA with principalaxis factoring as the extraction method. The Promax method was used for rotation because the
  • Sun et al. 539factors were thought to be correlated. The Kaiser–Meyer–Olkin’s measure (KMO) of samplingadequacy (acceptable level >.50; Kaiser, 1970) and Bartlett’s test of sphericity (Bartlett, 1950)were calculated to verify the appropriateness of an EFA. The number of factors was determinedusing parallel analysis (PA) performed with SPSS syntax developed by O’Connor (2000). Onlyitems with a strong loading (.50 or higher) on one factor and <.30 on any other factors wereretained to form latent variables because large loadings on factors other than the primary factorcould result in serious flaws in the factor structure (Costello & Osborne, 2005).The EFA with data from the 30-item ESSA indicated that the sample and correlation matrixwere appropriate for factor analysis (KMO Index = .88 and Bartlett’s test of sphericity was sig-nificant [c2(435, N = 347) = 3,675.80, p < .001]). Five factors were extracted based on PA analy-sis that cumulatively accounted for 52.1% of the total variance. However, several items werefound to have a poor loading (<.5) on all factors or had crossed loadings (loading ≥.3 in two ormore factors). These items were then dropped and a repeated EFA was conducted with remainingitems using the same method. This procedure was replicated until all retained items met the cri-teria. Finally, a 16-item scale was generated with all items having a strong loading on the primaryfactor but not on the other factors (Table 1).The appropriateness of the EFA for the revised 16-item ESSA was again justified, KMO = .81;Bartlett’s test: χ2(120, N = 347) = 1,495.83, p < .001. The number of factors remained thesame based on a repeated PA. Each factor contained at least three items (Table 1). The initialeigenvalues of five factors were 4.26, 2.30, 1.31, 1.22, and 1.07. The postrotation traces were3.20, 2.25, 1.96, 2.06, and 2.36, respectively. These latent variables explained 26.6%, 14.4%,8.2%, 7.6%, and 6.7% of variance, respectively, and together 63.6% of the total variance.Interfactor correlations ranged from .04 to .57. After carefully examining the meaning, thesefactors were labeled as Pressure from study, Workload, Worry about grades, Self-expectation,and Despondency (Table 1).ReliabilityThe internal consistency reliability was assessed using Cronbach’s alpha and average interitemcorrelation. A Cronbach’s alpha of .70 or higher or an average interitem correlation of .30 orhigher indicates acceptable reliability (Robinson, Shaver, & Wrightsman, 1991). The test–retestreliability was assessed with intraclass correlation coefficients (ICCs; Koch, 1982). An ICC of .2and lower indicates “poor,” .21 to .40 “fair,” .41 to .60 “moderate,” .61 to .80 “good,” and .80 orhigher as “almost perfect” reliability (Landis & Koch, 1977).On the basis of the data from the first survey (N = 347), the Cronbach’s alpha for the total16-item ESSA was .81 indicating good internal consistency. The coefficient alpha for each factorranged from .66 to .75, and most were above the criteria for an acceptable level of reliability(Table 2). The average interitem correlations for the five factors were .47, .50 .47, .39, and .39.Using the data from the second sample (N = 135), the ICC for the total ESSA score was .78and for the five factors was .75, .61, .70, .59, and .62, respectively, with the majority suggestinggood test–retest reliability. The ICC for each of the 16 items varied from .44 to .67 suggestingmoderate to good reliability more than 2 weeks.Concurrent and PredictiveValidityThe AESI (Ang & Huan, 2006a) served as a criterion measure to assess the concurrent validityof the ESSA. Scores from the two scales were hypothesized to be correlated because expecta-tions are an important source of academic stress among adolescents. Academic grades were alsohypothesized to be associated with educational stress with lower level students having more
  • 540Table2.Mean,StandardDeviation,AlphaCoefficients,andIntervariableCorrelationCoefficientsintheFirstSurvey(N=347)aM(SD)ab123456789101112 1. ESSAtotal54.14(9.32).811 2. Pressurefromstudy13.99(3.56).74.81**1** 3. Workload9.51(2.90).75.58**.39**1 4. Worryaboutgrades11.38(1.25).71.57**.34**.051 5. Self-expectation9.91(2.56).66.55**.27**.04.35**1 6. Despondency9.31(2.83).66.67**.44**.33**.14**.19**1 7. AESItotal30.61(6.46).85.51**.29**-.03.52**.83**.071 8. AESI–Otherexpectations17.22(3.86).81.41**.26**-.06.53**.58**.01.92**1 9. AESI–Self-expectations13.38(3.30).73.52**.26**-.01.39**.96**.13*.88**.62**110. CES-D(depression)15.34(8.93).87.47**.38**.25**.15**.24**.44**.19**.13*.22**111. SuicidalthoughtsNANA.17**.12*.13*.04.03.21**.**112. AcademicgradesNANA-.20**.10-.13*.03.02-.43**.16**.21**.07-.17**-.071Note:ESSA=EducationalStressScaleforAdolescents;AESI=AcademicExpectationStressInventory;CES-D=CentreforEpidemiologicalStudies–DepressionScale;NA=notapplicable.a.Pearsoncorrelationcoefficientsforcontinuousvariables;Point-biserialcorrelationcoefficientsforcorrelationsbetweensuicidalthoughtsandothers;Spearmanrforrelationshipsbetweenacademicgradesandothers.b.Cronbach’sacoefficient.*p<.05.**p<.01.
  • Sun et al. 541stress. To assess predictive validity, depression (CES-D score) and suicidal thoughts were usedas criterion measures because of their known associations with academic stress (Ang & Huan,2006b; Bjorkman, 2007; Liu & Tein, 2005). The expected relationships were analyzed usingPearson correlation for continuous variables, point-biserial correlation for associations betweenESSA scores and suicidal thoughts, and Spearman correlation for relationships between aca-demic grades and others.As expected, the ESSAtotal score was significantly correlated with theAESI scores (Table 2).Three ESSA factors, that is, Pressure from study, Worry about grades, and Self-expectation werealso significantly correlated with AESI total and subscales (Table 2). However, there were nosignificant correlations between other two ESSA factors (Workload and Despondency) and AESIscores (Table 2).The overall ESSA score was negatively correlated with academic grades (Spearman r = -.20,p < .001), indicating that students with low academic achievements have more stress. However,only two of the five factors (Workload and Despondency) showed significant correlations withself-reported academic grades (Table 2).Total academic stress and all factors were positively correlated with CES-D score (Table 2).The coefficient for overall stress (.47) approached a moderate effect size according to Cohen’s(1988) criteria (r = .5). There were also significant correlations between suicidal thoughts andtotal ESSA score and scores of two of the factors (Pressure from study and Despondency, Table 2).CFAUsing Amos 7.0 (SPSS, Chicago, IL), a CFA was conducted to assess the fit of the exploratorymodel to the data from the third sample (N = 1,670). The maximum likelihood method was usedto estimate these parameters (Byrne, 1994). Missing data were rare (all items <1%) and assumedto be missing at random.Aset of goodness of fit indices were calculated, including the traditionalChi-Square Fit Index, Comparative Fit Index (CFI), Bentler-Bonett Normed Fit Index (NFI),Incremental Fit Index (IFI), GFI, root mean square error of approximation (RMSEA), and thestandardized root mean square residual (SRMR). A value of .90 or higher for CFI, NFI, IFI, andGFI; an RMSEA of .06 or lower; and an SRMR of .05 or lower were served as the indicators foran adequate fit (Byrne, 1994; Hu & Bentler, 1999; MacCallum, Brown, & Sugawara, 1996).According to the results of the traditional Chi-Square Fit Index, c2(94, N = 1,670) = 604.59,p < .001, the observed model was significantly different from the expected model. However, thismay be related to the large sample size. All other indices, including the CFI (.93), NFI (.92), IFI(.93), GFI (.96), RMSEA (.06), and SRMR (.05) suggested an adequate fit to the original factorstructure. The factor loading for each item on the corresponding factor in the CFA was similar tothe results from the EFA and all were above .50 (Table 1).Considering the large correlation between the overall score and each subscale (Table 2), there islikely a second-order factor. We thus conducted a repeated CFAto test the alternative model includ-ing a second-order factor. Compared with the first model, all indices slightly changed and some ofthose fell below the adequacy criteria (Chi-Square Fit Index [c2(99, N = 1,670) = 815.57, p < .001];CFI = .90; NFI = .89; IFI = .90; GFI = .94; RMSEA = .07; and SRMR = .07). However, threeindices—CFI, IFI, and GFI—were still above the criteria for an adequate fit. The factor loadingsfor the 5 first-order factors on the second-order factors were .97, .64, .40, .44, and .73, respectively.DiscussionA new instrument for academic stress was developed and validated in this study with more than2,000 adolescents from urban and rural areas of Shandong, China. The final scale contains 16
  • 542 Journal of Psychoeducational Assessment 29(6)items and 5 latent variables, that is, Pressure from study, Workload, Worry about grades,Self-expectation, and Despondency. Scores from this scale exhibit satisfactory psychometricproperties in terms of internal and test–retest reliability and concurrent and predictive validity.Application of a relatively high criterion to retain items in the final scale (Costello & Osborne,2005) resulted in nearly half (14 items) of the initial items being dropped because of poor loadingon the primary factor and high loadings on the other factors. By doing this, there may be a riskthat the subscales suffer from construct underrepresentation, which might also be related to theslightly low internal consistency of some factors. However, given that the application of thisinstrument is for school- or community-based survey of students to examine the magnitude andhealth associations of academic stress, rather than for clinical diagnostic purposes, a brief scalewith clear factor structure may be preferable than a lengthy but more accurate one. The relativelylow Cronbach’s alphas for some factors are likely to be caused by the small numbers of items perscale. The average interitem correlations for all factors are well above the criterion (≥.30) for anacceptable internal consistency (Robinson et al., 1991), indicating the items within each subscaleare highly correlated. In addition, the number of items in each factor meets the minimum numberof three items for best practice in factor analysis (Costello & Osborne, 2005). More importantly,the number of factors determined using PA did not change even after dropping poor or crossloaded items, indicating minimal change to the factor structure.CFA is essential in the development of a new scale and should be conducted with data froma different sample from the EFA (Hinkin, 1998). Using a large, separate sample (N = 1,670), wetested the fit of the factor model of the 16-item ESSA and found an adequate fit according to arange of indices. All indices except the Chi-Square Fit Index meet the recommended thresholdsfor an adequate fit. The high value of the Chi-Square Index is likely related to the large samplesize (N = 1,670). Although all indices negatively changed in a repeated CFA involving a second-order factor, there is still evidence to suggest that the revised model has adequate fit and theconstruction of an aggregated ESSA total score is appropriate. However, the factor loadings for2 first-order factors, that is, Worry About Grades and Self-Expectation are relatively low (.40and .44), suggesting further analysis is necessary to examine the convergent and discriminantvalidity of the ESSA.Academic expectations are an important source of stress among Asian students (Ang & Huan,2006a). As expected, the ESSA score was significantly correlated with the AESI score, indicat-ing a satisfactory concurrent validity. Two factors in the ESSA, Worry About Grades and Self-Expectation obtained relatively high correlation coefficients with the AESI–Other expectationsand AESI–Self-expectations (r = .53 and .96, Table 2). This is because two items (Items 9 and10, Table 1) of Worry about grades and all items (Items 14-16, Table 1) were adapted from theAESI with minor changes, although the response format (from strongly disagree to stronglyagree) differs from the AESI (from never true to almost always true). Two other factors, Despon-dency and Workload, are not captured by the AESI that supports the value of development of anew multifactorial scale.Academic stress is recognized as a risk factor for depression and suicidal behavior (Ang &Huan, 2006b; Bjorkman, 2007). In this study, the ESSA scores show significant associationswith these health problems. Compared with the AESI, the ESSA scores appear to be more predic-tive of depression and suicidality (Table 2). This is probably because the ESSA captures moreelements of academic stress than the AESI. In relation to the suicidal thoughts and academicgrades, the ESSA scales have relatively poor predictive validity (see Table 2). One explanationis that academic stress is only one of the correlates that are associated with these two variables.Many other factors—such as loss of loved ones; conflicts with parents, teachers, and peers; andsignificant physical diseases—may have important effects on adolescent suicidality (Liu & Tein,2005). Similarly, although poor academic grades generally predict high educational stress, the
  • Sun et al. 543discrepancy between expected and actual grades may play a more important role in the developmentof psychological distress and other mental health problems (Lin et al., 2008). In addition, thiscould be also related to the poorly measured criterion variables, as suicidal thoughts does notinclude an academic component and academic grades was not very precise given its subjectivenature. More suitable criterion measures should be used in future research.This study has some implications for educational policy and practice, including school coun-seling. A brief tool with sound psychometric properties could be used to examine the nature andmagnitude of the phenomenon in many educational contexts and to inform the design and imple-mentation of interventions to reduce educational stress in schools. Students’ mental health andwell-being have been drawing increasing attention in China where school counseling has beenmade available only in recent years. School counselors should have a good understanding of themultifactorial nature of educational stress and its links to common mental and behavioral prob-lems among students to inform best practice in counseling.This study has some limitations. First, the development of the items in the ESSA wasmainly based on review of recent Chinese and English literature plus informal discussionswith experts. No attempt was made to more comprehensively map the construct usinggrounded theory to explore an underlined model. Second, despite the identification of fivefactors with just 16 items, the ESSA cannot capture all facets of educational stress. Morework should be done to further investigate the multidimensional nature. Third, the ESSAwas only tested with Chinese adolescents in Shandong, and cross-cultural suitability is yetto be established. Therefore, this work should be viewed as a starting point of a continuousprocess of validation and revision. Fourth, we used a single question to measure self-reportacademic grades, but we do not know if there are disparities between perceived grades andactual grades. Actual scores are ideal but very difficult to obtain in a self-report anonymoussurvey. Further research is needed to examine the difference between self-report and actualgrades and their relationships with stress and other outcomes. Sixth, information in thisstudy was collected solely relying on self-report of students and hence some recall bias cannotbe avoided.Nevertheless, this newly developed scale demonstrates satisfactory psychometric propertiesand is suitable to be used in further research into academic-related stress among secondaryschool adolescents. The ESSA promises to be a useful tool at least with Chinese populations andin other Asian countries and possibly useful in different social and cultural contexts.AcknowledgmentsThe authors thank all participating students and schools. Assistance with statistical analysis wasprovided by Dr. Jason Dixon and Dr. Cameron Hurst of QUT School of Public Health, and Dr. CameronNewton from QUT Business School. The authors would like to thank Dr. Rebecca P. Ang of NanyangTechnological University, Singapore for her kind permission to use the AESI and the adoptions of AESIscales in our study.Declaration of Conflicting InterestsThe author(s) declared that they had no conflicts of interest with respect to their authorship or the publica-tion of this article.FundingThe author(s) disclosed that they received the following support for their research and/or authorship ofthis article: This study was sponsored by a Research Development Grant of QUT and a QUT Grant-in-Aid. This work also gained in-kind support of Shandong Provincial Centre for CDC and ShouguangCDC.
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  • 546 Journal of Psychoeducational Assessment 29(6)Zeidner, M. (1992). Sources of academic stress: The case of 1st year Jewish and Arab college-students inIsrael. Higher Education, 24, 25-40. doi:10.1007/BF00138616Zhang, H., Tao, F., & Zeng, G. (2001). Depression and its correlates among middle school students inAnhuiprovince. Chinese Journal of School Health, 22, 497-498.BiosJiandong Sun, is a PhD scholar in Social Epidemiology at the School of Public Health, Queensland Uni-versity of Technology (QUT), Australia. He is also a former epidemiologist in China and a current epidemi-ologist in Queensland Health, Australia. His research interests include adolescent mental health andwellbeing, psychometrics, suicidology and methods for disease surveillance.Michael Dunne, is a psychologist and Professor of Social Epidemiology at School of Public Health, QUT,Australia. His research focuses on the mental health of young people and adults in East Asian communities,and includes studies of the prevalence and consequences of adverse childhood experiences.Xiang-yu Hou, is a medical practitioner and a senior lecturer in epidemiology at School of Public Health,QUT, Australia. Her research interests are emergency medicine and international health, including mentalhealth in developing countries.Ai-qiang Xu, is the Vice-director of the Shandong Center for Disease Control and Prevention (ShandongCDC), China and a professor in Epidemiology at Shandong University. He has extensive research interestsin Public Health with a focus on communicable disease prevention in particular national immunizationprogramme and implementation, non-communicable disease epidemiology and youth mental health.
  • 1Under peer-review, Asia Pacific Journal of Public HealthVALIDATION OF THE ‘EDUCATIONAL STRESS SCALEFOR ADOLESCENTS’ (ESSA) IN VIETNAMTT Truc – Lecturer, Ho Chi Minh City University of Medicine and Pharmacy,Vietnam, email: Loan – Lecturer, Ho Chi Minh City University of Medicine and Pharmacy,Vietnam, email: Nguyen – Associate Professor of Public Health, Ho Chi Minh City University ofMedicine and Pharmacy, Vietnam, nguyendonguyen@yahoo.comJ Dixon – Research fellow in mental health, School of Public Health, QueenslandUniversity of Technology, Australia, email: Sun – PhD of Public Health, School of Public Health, Queensland University ofTechnology, Australia, email: Dunne - Professor of Social Epidemiology, School of Public Health, QueenslandUniversity of Technology, Australia, email: for correspondence: Thai Thanh Truc, 159 Hung Phu, District 8, Ho ChiMinh City, Vietnam. Email:
  • 2Under peer-review, Asia Pacific Journal of Public HealthAbstractIntroduction: To date, there has been little systematic, quantitative research on thelinks between academic pressure and mental health among adolescents in Asia, andnone in Vietnam. In part, this is due to a lack of appropriate tools to measure thiscomplex phenomenon. This study was to validate the Educational Stress Scale forAdolescents (ESSA), developed and tested in China, with the aim of fostering furtherresearch in Asia. Methods: 1283 students were recruited in three secondary schoolsand three high schools in Ho Chi Minh City, Vietnam. Anonymous, self-reportquestionnaires included the ESSA and previously validated measures of mental health.Results: Among 1226 questionnaires available, 54% of respondents were female. Themean age was 15.3 years. Students reported substantial study burden. The ESSA hadgood internal consistency and factorial validity and concurrent validity wereestablished. Conclusion: The ESSA is a suitable measure for school-based mentalhealth research in Asia.Keywords: adolescents‟ stress, confirmatory factor analysis; educational stress;mental health; psychometric properties, VietnamIntroductionIn recent years, studies in western countries have revealed a strong relationshipbetween academic stress and depression, anxiety, low self-esteem and suicidalideation among students in secondary schools and high schools and in tertiaryeducation1, 2, 3. Similar to psychological stress in general, academic or educationalstress is a subjective state associated with an individual‟s perception of possible future
  • 3Under peer-review, Asia Pacific Journal of Public Healthoutcomes or consequences related to academic performance and in reaction to externalstressors, including the burden imposed by people and school systems.Although adolescent mental health is influenced by a wide range of life eventsand situations, such as community and family disharmony, financial problems andpoor peer relationships, educational activities are among the most important sources ofstress for young people in Western and Asian countries4, 5, 6. In China, students withhigh levels of educational stress are more likely to experience depression, suicidalthinking and unhappiness7. In Vietnam, although several studies have been recentlyconducted about adolescent mental health, there has not been any in-depth orsystematic research on educational stress and its consequences on adolescent health.In part, this is due to a lack of appropriate tools to measure this complex phenomenon.Sun, Dunne, Hou and Xu (2011) recently developed and validated theEducational Stress Scale for Adolescents (ESSA)8. This 16-item scale was derivedfrom an initial pool of 30 items that emerged from qualitative interviews and reviewof existing tools. It covers five dimensions including pressure to study, worry aboutgrades, self expectation, workload and study despondency. Pressure to study relates toperceived pressure from future education and employment, from parents and theschool environment. Worry about grades relates to personal anxiety aboutexamination performance at school. Self expectation stress concerns perceived stressfrom failure to meet one‟s own educational goals, while workload refers to stress dueto excessive study time, homework and the burden of assessments. Study despondencyrefers to lack of confidence and concentration in class and dissatisfaction with overallacademic performance. Worry about grades, self expectation stress and despondency
  • 4Under peer-review, Asia Pacific Journal of Public Healthcan be considered to be internal aspects of educational stress, while pressure to studyand workload are externally driven aspects8. In a survey of 1,670 junior to senior highschool students in Shandong province China, the scale was found to have goodpsychometric properties, including high internal consistency and test-retest reliability,and factorial and concurrent validity.For this new scale to be useful cross-culturally, it is necessary to determine thepsychometric properties in different languages and countries. The aim of this studywas to evaluate the ESSA among students in secondary schools and high schools inVietnam. The scale once validated could be integrated into multivariable research toexplore determinants of mental health of adolescents.MethodsParticipantsA cross-sectional survey was conducted with students aged 13-19 in threesecondary schools (years 8, 9) and three high schools (years 10 – 12) in Ho Chi Minhcity, Vietnam. A total of 1283 students were recruited. Only 5 students refused toparticipate and 52 questionnaires were incomplete. The number of questionnairesuitable for analysis was 1226 (95.6% completion rate). Participants were asked abouttheir demographic characteristics, family environment, school environment, mentalhealth, health risk behaviors and educational stress.MeasuresEducational stress was measured by the ESSA. Responses to the 16 items areon a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). The Englishlanguage version has been published8and the Vietnamese version is shown in
  • 5Under peer-review, Asia Pacific Journal of Public HealthAppendix 1. The formatted Chinese, English and Vietnamese versions are availablefrom the first author ( health variables included depression, anxiety, psychological distressand general well-being. The scales employ Likert-type response formats and havebeen previously validated in Vietnam and in Asian countries9-13.The Centre for Epidemiological studies-Depression Scale (CES-D) includes 20self-reported items designed by the US National Institute of Mental Health to measuredepressive symptoms in the general population. The scale has high internalconsistency (coefficient alpha = 0.85) and strong validity including construct validity,discriminant validity, concurrent validity and criterion-related validity14. Research inVietnam indicates good to very good internal consistency, with Cronbach‟s alphafrom 0.72 to 0.8512, 15. The anxiety scale consisted of 13 items using 3-point responses(never, sometimes, often)12. The scale has good internal consistency (Cronbach‟salpha ranged from 0.76 to 0.81)12, 15.The Kessler Psychological Distress Scale (K-10) is comprised of 10 items with5-point responses from 1 (none of the time) to 5 (all of the time)16. The internalconsistency coefficient of the original scale was α=0.93. Concurrent validity andcriterion-oriented validity have been established17, 18. The World HealthOrganization‟s „WHO-5 Well-being Index‟ has 5 positively worded items aboutemotional well-being over the last two weeks19. Internal consistency and test-retestreliability are excellent (alpha = 0.90) while the concurrent and construct validity ofthe scale are acceptable20. Criterion related validity against Statistical Manual ofMental Disorders (DSM-IV) has also been established for the WHO-521.
  • 6Under peer-review, Asia Pacific Journal of Public HealthProcedureThe questionnaire was originally prepared in English and then translated intoVietnamese using forward and backward translation procedures. Some minor changesto wording of some items were done following a pilot study of 20 students inVietnam. Two focus-group discussions were conducted to ensure that respondentsclearly understand the questionnaire and response options. No changes were madeduring the English to Vietnamese translation of the ESSA.Three secondary schools and three high schools were randomly selected from alist. Two classes were randomly recruited for each grade (grade 8 and 9 in secondaryschools and grade 10, 11 and12 in high schools. All students from selected classeswere invited to complete a self administered questionnaire without the presence oftheir teachers in the room. The researchers remained in classrooms to answerquestions raised by students and to assist them if necessary.Participation was by informed consent of the students and entirely anonymousand voluntary. The students were asked to sit at least one meter apart to ensureprivacy. Completed questionnaires were placed into individual envelopes, sealed andput into a box to ensure total anonymity. Free counselling service was offered to thestudents who might experience some distress as the result of their participation in theresearch.EthicsThe research protocol was approved by Human Research Ethics Committee atQueensland University of Technology, Australia and the Scientific Review Committeeof the Ho Chi Minh City University of Medicine and Pharmacy, Vietnam.
  • 7Under peer-review, Asia Pacific Journal of Public HealthData analysisSPSS 17 and AMOS 17 were used for data analysis. To investigate thereliability and validity of the scales, Cronbach‟s alpha, Pearson correlations andConfirmatory Factor Analysis (CFA) were employed. The Cronbach alpha coefficienthas a recommended threshold of 0.7 to indicate good internal consistency22. However,alpha of 0.6 is considered acceptable23. The following fit indices were used for CFA:Chi square statistic; the Comparative Fit Index (CFI) where values of > 0.90 indicate agood fit24; Goodness of Fit Indices (GFI) where values of > 0.90 show a well fittingmodel24; Incremental Fit Indices (IFI) where values of > 0.90 indicate a good fit25andRoot Mean Square Error of Approximation (RMSEA) with 90% confidence intervalwhere values ranged from 0.06 to 0.08, which suggest an acceptable fit25.Comparisons with findings from the Chinese validation study8were also done toexamine similarities and differences between the original scale used in China and itsperformance in Vietnam.ResultsParticipant characteristicsThe respondents (54.8% female) had a mean age of 15.3 ± 1.4 years. Out of1226 participants, 35.8% were secondary students (16.1% grade 8 and 19.7% grade 9)and 64.2% were high school students (21.5% grade 10, 21.5% grade 11 and 21.1%grade 12). Most of the participants were currently living in Ho Chi Minh City andonly 5% reported family residence in other cities/provinces. There was 12.9%participants reported parental marriage as divorced or separated. The majority ofadolescents in this study had one sibling while 16.7% of them were the only child.
  • 8Under peer-review, Asia Pacific Journal of Public HealthRegarding after school study hours, 39.7% reported spending on average less than 2hours per day, while 30.4% reported 2 to 3 hours and 29.9% more than 3 hours. Moststudents said they had personal tutors to help with studying (62.2%) and nearly half(47%) had attended classes during weekends or holidays in the previous 12 months.The mean score for K-10, CES-D, anxiety scale and WHO-5 were 22.8 ± 7.2,15.1 ± 9.9, 21.3 ± 4.1 and 14.0 ± 6.6 respectively. These figures were different inmales and females where females had higher mean score on CES-D, anxiety and K-10and lower mean score on WHO-5. The ESSA total score had a mean of 54.5 ± 9.7 andwas also different in males and females (see Table 1).Internal consistencyThe result indicated that total ESSA and all mental health scales and the ESSAhad good to excellent internal consistency (see Table 3). The Cronbach‟s alpha for theK-10, CES-D, anxiety scale and WHO-5 were 0.86, 0.86, 0.74 and 0.90 respectively.The ESSA had an alpha of 0.83, which indicates very good internal consistency in thisVietnamese setting. The five sub-scales of the ESSA had lower but acceptable levelsof internal consistency with alpha of 0.70, 0.65, 0.66, 0.62 and 0.78 for pressure tostudy, worry about grade, study despondency, self expectation stress and workloadrespectively. The item-rest correlation and item-test correlation of each item in thescale was from moderate to strong (table 2).Construct and Concurrent ValidityThe confirmatory factor analysis showed an unfit 5-factor model using Chi-squared fit index (χ2(94) = 610.7, p<0.001) which indicated a significant differencebetween the observed model and expected model. However, this statistics is affected
  • 9Under peer-review, Asia Pacific Journal of Public Healthby the large sample size. The χ2value is normally inflated and shows statisticalsignificance and thus rejects the model with large sample size25. Values of other fitindices such as CFI (0.907), IFI (0.907), GFI (0.942), and RMSEA (0.067; 90% CI =0.062 – 0.072) revealed a good fit of the model specified. Five factors had moderate tostrong correlation with one another with covariances ranging from 0.10 to 0.62. Factorloadings ranged from 0.39 to 0.87 (see Figure 1). Multiple squared correlationcoefficients ranged from 0.15 to 0.75 indicating that the factors contributed acceptableto good explanation to the variation of items used in the model. Together, these dataindicate that the ESSA has adequate factorial validity.The ESSA showed good concurrent validity. The ESSA scores correlated withother validated scales in the direction that indicates a significant influence on mentalhealth (see Table 3). The ESSA scores were positively correlated with depression,anxiety and psychological distress and negatively correlated with subjective well-being. The ESSA subscale scores also correlated with mental health. All correlationswere statistically significant except between Pressure to Study and WHO-5 Well-being.DiscussionIn this Vietnamese context, the ESSA had very good internal consistencywhich was similar to the original version8. However, five sub-scales of the ESSArevealed a lower level of reliability than in Sun et al‟s study8with alpha ranging fromα=0.62 to α=0.78. Although many previous studies adopt a threshold of 0.7 todetermine good internal consistency, an alpha as low as 0.6 can be considered
  • 10Under peer-review, Asia Pacific Journal of Public Healthacceptable23. Further, each of the ESSA subscales has only 3 or 4 items andcoefficient alpha is expected to be lower in scales with less items27.The ESSA showed a good fit to a 5-factor model using CFI, IFI, GFI andRMSEA although traditional Chi-squared test revealed an unfit. This may arisebecause the Chi-squared test affected by the sample size27. These figures wereconsistent with the study by Sun et al in China8, where the five-factor model did notsatisfy the Chi squared test but had good fit indices including CFI, IFI and GFI.Overall, it is clear that the ESSA can be considered to have adequate factorial validity.Furthermore, the model also demonstrated similar covariance between the five factorsas in Sun et al study8, where despondency and self expectation shared high covariance(0.63) as did pressure from study and workload (0.62). These figures indicate that„internal‟ factors including despondency and self expectation are closely correlated,while „external‟ factors such as pressure from study and workload are correlated in ameaningful way.With respect to associations between educational stress scores and mentalhealth, the ESSA moderately correlated with depression (CES-D; r=0.37), anxiety(r=0.36) and psychological distress (K-10; r=0.42) which indicates concurrent validityof the ESSA. The concurrent validity was also well-established through the directionof correlation between the ESSA scores and positive as well as negative mental healthmeasurements. Further, the correlation between factors of ESSA and mental healthissues were also checked. The ESSA subscales including pressure to study,despondency and self expectation also correlated with mental health measures. Worryabout grades and workload were not correlated with mental health scores as the
  • 11Under peer-review, Asia Pacific Journal of Public Healthquestions themselves refer to other aspect such as study burden rather than mentalhealth issues (e.g. “I feel that there are too many test/exams in the school”). Thefinding was consistent with Sun‟s report8.This study had some strengths and limitations. The sample was quite large andhad a high response rate and had consistent participants‟ characteristics with previousstudies in Vietnam. Further, the study investigated mental health problems quitebroadly, including both positive and negative states. This was a good contributionbecause most previous studies only focus on the negative aspects of mental healthoutcomes. Moreover, this study was the first to evaluate the newly developed scale,the ESSA, in a second language and cultural setting. Findings from this study suggeststrong grounds for employment of this scale in future studies in Vietnam. Onelimitation was that information was collected solely through self-report format whichmight result in recall bias. A second limitation is the sample was drawn from innercity schools in a large city and might not be generalizable to all school students inVietnam. Further work is necessary to assess psychometric properties of the scalesuch as test-retest reliability, predictive validity or criterion validity and theeducational stress experiences of young people in rural areas.ConclusionThe factorial and concurrent validity of the ESSA in Vietnamese context is similar tothat found in Chinese schools. It may be a suitable measure to consider for school-based mental health research in Asian cultures. However, more research should bedone to investigate the appropriateness of the tool among adolescents in rural areas.References
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  • 13Under peer-review, Asia Pacific Journal of Public Health25. Hu L-t, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis:Conventional criteria versus new alternatives. Struct Eq Modeling. 1999;6(1):1 - 55.26. Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika.1951;16(3):297-238.27. Lance CE, Butts MM, Michels LC. The Sources of Four Commonly Reported Cutoff Criteria.Organ Res Methods. 2006;9(2):202-220.
  • Table 1: study environment and mental health by gender (N = 1226)Variables TotalSexMale FemaleSTUDY ENVIRONMENT n (%) n (%) n (%)Extra hours per days spend on studying after school in the past 12 months< 2 hours 486 (39.7) 257 (46.4) 229 (34.1) ***2 – 3 hours 373 (30.4) 170 (30.7) 203 (30.2)> 3 hours 367 (29.9) 127 (22.9) 240 (35.7)Had personal tutor(s) to help your study in the past 12 monthsYes 763 (62.2) 335 (60.5) 428 (63.7)No 463 (37.8) 219 (39.5) 244 (36.3)Attended classes during weekends or holidays in the past 12 monthsYes 576 (47.0) 244 (44.0) 332 (49.4)No 650 (53.0) 310 (56.0) 340 (50.6)MENTAL HEALTH Mean (SD) Mean (SD) Mean (SD)Depression (CESD) 15.10 (9.9) 13.6 (9.2) 16.4 (10.3) ***Anxiety 21.3 (4.1) 19.7 (3.6) 22.6 (4.0) ***Psychological distress (K10) 22.8 (7.2) 21.8 (7.0) 23.6 (7.2) ***Mental well-being (WHO5) 14.0 (6.6) 15.3 (6.3) 12.9 (6.7) ***Educational stress (ESSA) 54.5 (9.7) 53.0 (9.7) 55.7 (9.6) ***P value: *** < 0.001 < ** < 0.01 < * < 0.05Table 2: Internal consistency reliability of the ESSA (N = 1226)ItemItem-testcorrelationItem-restcorrelationAlphaES1 0.53 0.43 0.82ES2 0.50 0.41 0.82ES3 0.48 0.38 0.82ES4 0.65 0.57 0.81ES5 0.50 0.39 0.82ES6 0.65 0.57 0.81ES7 0.52 0.44 0.82ES8 0.40 0.30 0.82ES9 0.54 0.45 0.82ES10 0.44 0.34 0.82ES11 0.55 0.46 0.82ES12 0.62 0.54 0.81ES13 0.48 0.38 0.82ES14 0.54 0.44 0.82ES15 0.54 0.45 0.82ES16 0.50 0.39 0.82TOTAL 0.83
  • Table 3: Correlation matrix between scale used in the studyScaleItems Mean(SD)Cronbach‟s alpha1 2 3 4 5 6 7 8 9 101. ESSA 16 54.5 (9.7) 0.83 12. ESSA-Pressure from study 4 12.9 (3.5) 0.70 0.80** 13. ESSA-Worry about grade 3 11.4 (2.5) 0.65 0.60** 0.30** 14. ESSA-Despondency 3 9.3 (2.7) 0.66 0.70** 0.43** 0.36** 15. ESSA-Self expectation 3 10.1 (2.7) 0.62 0.69** 0.39** 0.38** 0.42** 16. ESSA-Workload 3 10.8 (2.7) 0.78 0.60** 0.50** 0.10** 0.22** 0.20** 17. CES-D 20 15.1 (9.9) 0.86 0.37** 0.34** 0.08* 0.35** 0.31** 0.15** 18. Anxiety Scale 13 21.3 (4.1) 0.74 0.36** 0.28** 0.17** 0.28** 0.31** 0.17** 0.44** 19. Distress (Kessler 10) 10 22.8 (7.2) 0.86 0.42** 0.37** 0.15** 0.34** 0.35** 0.21** 0.70** 0.45** 110. Well-being (WHO-5) 5 14.0 (6.6) 0.90 -0.31** -0.32** -0.00 -0.28** -0.22** -0.21** -0.60** -0.29** -0.47** 1P value: *** < 0.001 < ** < 0.01 < * < 0.05
  • Figure 1: Confirmative Factor Analysis for ESSA
  • 1Under peer-review, Asia Pacific Journal of Public HealthAppendix 1: Educational Stress Scale for Adolescent (Vietnamese)ID Question Factor*ES1 Tôi cảm thấy rất thất vọng về điểm học tập của tôi 3ES2 Tôi cảm thấy có quá nhiều bài ở trường 5ES3 Tôi có quá nhiều bài tập về nhà để làm 5ES4 Nghĩ về việc học trong tương lai tạo nhiều áp lực học tập đối với tôi 1ES5 Ba mẹ tôi quan tâm quá nhiều đến việc học của tôi tạo nhiều áp lực đối với tôi 1ES6 Tôi cảm thấy việc học hàng ngày có nhiều áp lực đối với tôi 1ES7 Có quá nhiều bài kiểm tra và kì thi trong trường 5ES8 Thành tích học tập của tôi là rất quan trọng cho tương lai tôi và thậm chí nó quyếtđịnh toàn bộ cuộc đời của tôi2ES9 Tôi cảm thấy tôi đã làm thất vọng ba mẹ tôi khi kết quả bài thi/kiểm tra của tôi thấp 2ES10 Tôi cảm thấy tôi đã làm thất vọng thầy cô tôi khi kết quả bài thi/kiểm tra của tôikhông hoàn hảo (lý tưởng)2ES11 Có quá nhiều cạnh tranh trong việc học với các bạn trong lớp mang lại nhiều áp lựchọc cho tôi1ES12 Tôi luôn thiếu tự tin với điểm số học tập của tôi 3ES13 Tôi rất khó tập trung trong giờ học 3ES14 Tôi thấy căng thẳng khi tôi không sống theo tiêu chuẩn của chính mình 4ES15 Khi tôi không đạt được kì vọng tôi đặt ra, tôi thấy tôi không đủ giỏi 4ES16 Tôi thường không thể ngủ và thấy lo lắng khi tôi không thể đạt được mục tiêu tôi đặtra cho chính mình4* 1-Pressure to study; 2-Worry about grade; 3-despondencey; 4-self expectation; 5-workload
  • | TOÅNG QUAN & NGHIEÂN CÖÙU |Taïp chí Y teá Coâng coäng, 1.2007, Soá 7 (7) 25Giaù trò vaø ñoä tin caäy cuûa hai thang ño traàmcaûm vaø lo aâu söû duïng trong nghieân cöùu coängñoàng vôùi ñoái töôïng vò thaønh nieânTS. Nguyeãn Thanh Höông, PGS.TS. Leâ Vuõ Anh,GS.TS. Michael DunneNhöõng vaán ñeà veà söùc khoûe taâm thaàn trong thôøi kyø vò thaønh nieân coù moái lieân quan chaët cheõ vôùi raátnhieàu haønh vi nguy cô coù theå gaây aûnh höôûng töùc thì hoaëc laâu daøi tôùi söùc khoûe. Tröôùc nhöõng haäu quaûdo roái loaïn taâm thaàn gaây ra, nhu caàu thöïc hieän caùc nghieân cöùu coäng ñoàng lieân quan ñeán söùc khoûetaâm thaàn vò thaønh nieân ngaøy caøng taêng. Cho ñeán nay chöa coù nghieân cöùu naøo coâng boá keát quaû kieåmñònh giaù trò vaø ñoä tin caäy cuûa caùc coâng cuï ño löôøng söùc khoûe taâm thaàn vò thaønh nieân taïi coäng ñoàngôû Vieät Nam. Muïc tieâu cuûa nghieân cöùu naøy nhaèm: (1) Ñaùnh giaù giaù trò vaø ñoä tin caäy cuûa thang ñotraàm caûm cuûa Trung taâm nghieân cöùu dòch teã hoïc (CES-D), Myõ. (2) Xaây döïng vaø böôùc ñaàu ñaùnh giaùthang ño nhoùm trieäu chöùng lo aâu, ñeå coù theå söû duïng trong caùc nghieân cöùu coäng ñoàng vôùi ñoái töôïngvò thaønh nieân Vieät Nam. Baûn dòch CES-D vaø thang ño lo aâu do chuùng toâi xaây döïng ñöôïc kieåm ñònhvôùi 299 em hoïc sinh coù ñoä tuoåi töø 13 ñeán 18 ôû huyeän Chí Linh, tænh Haûi Döông vaø quaän Ñoáng Ña,Haø Noäi. Keát quaû phaân tích yeáu toá thaêm doø (EFA) cho thaáy thang ño lo aâu goàm 13 tieåu muïc phaânthaønh 3 nhoùm thaønh toá roõ raøng coù moái lieân quan cao (>0,50) trong moãi thaønh toá. Moâ hình goác goàm4 thaønh toá cuûa CES-D ñaõ ñöôïc laëp laïi trong nghieân cöùu naøy qua keát quaû phaân tích yeáu toá khaúng ñònh(CFA). Caùc chæ soá thoáng keâ cuûa CFA ñeàu ñaït keát quaû toát vôùi CFI, GFI, NFI >0,90 vaø RMSEA = 0,053.Caû hai thang ño ñeàu coù ñoä tin caäy cao veà söï nhaát quaùn beân trong (thang ño lo aâu: α = 0,82 vaø CES-D: α = 0,87). Hai coâng cuï naøy ñeàu ñaûm baûo chaát löôïng, coù theå söû duïng trong caùc nghieân cöùu coängñoàng vôùi ñoái töôïng vò thaønh nieân ôû Vieät Nam.Töø khoùa: Giaù trò, ñoä tin caäy, traàm caûm, lo aâu, vò thaønh nieân.Poor mental health during adolescence has been linked with behaviours which can damage physicalhealth both in the short-and long-term. Given a worldwide epidemic of psychological disorders, theneed to conduct community-based studies on adolescent mental health issues is increasing. There hasbeen no previous study in Vietnam validating instruments measuring adolescent depression and anx-iety. The objectives of the present study are: (1) To validate the self-reported CES-D (The Center forEpidemiological Studies-Depression Scale) originally developed in the US. (2) To develop and con-duct a preliminary validation of a self-reported short form anxiety scale for adolescents. Vietnameseversions of the CES-D and the new anxiety scale were tested with 299 school students aged 13-18years in Chi Linh and Dong Da districts. Exploratory factor analysis (EFA) showed that the 13-itemanxiety scale clearly loaded into 3 components with the factor loading values more than 0.50.CES-Ds original model of 4 factors was replicated in this study using confirmatory factor analysis(CFA). CFAs statistical indices indicated good results with CFI, GFI, NFI >0.90 and RMSEA =0,053. Both scales had good internal consistency (anxiety scale: α = 0.82 and CES-D: α = 0.87).These two scales have good psychometric properties and it is recommended that they could be usedin community-based research among adolescents in Vietnam.Key words: Validity, reliability, depression, anxiety, adolescents.
  • 26 Taïp chí Y teá Coâng coäng, 1.2007, Soá 7 (7)| TOÅNG QUAN & NGHIEÂN CÖÙU |1. Ñaët vaán ñeàSöùc khoûe taâm thaàn vò thaønh nieân laø moät vaán ñeàñang ngaøy caøng thu huùt söï quan taâm cuûa caùc caùn boäquaûn lyù, caùn boä y teá vaø coäng ñoàng. Söùc khoûe taâmthaàn ñöôïc ñaùnh giaù laø moät caáu phaàn quan troïngtrong söùc khoûe toång theå cuûa theá heä treû. Nhöõng vaánñeà veà söùc khoûe taâm thaàn trong thôøi kyø vò thaønh nieâncoù moái lieân quan chaët cheõ vôùi raát nhieàu haønh vinguy cô nhö töï töû, uoáng röôïu, huùt thuoác, söû duïng matuùy, coù theå gaây aûnh höôûng töùc thì hoaëc laâu daøi tôùi söùckhoûe theå chaát cuõng nhö taâm thaàn khi tröôûng thaønh.ÔÛ caùc nöôùc phaùt trieån, trong khi soá lieäu thoáng keâ chothaáy coù nhöõng keát quaû khaû quan veà söï caûi thieänñaùng keå söùc khoûe theå chaát vò thaønh nieân, thì söùckhoûe taâm thaàn cuûa nhoùm ngöôøi treû tuoåi naøy chöañöôïc giaûi quyeát hieäu quaû vaø vaãn laø gaùnh naëng beänhtaät chuû yeáu1.Töø laâu, caùc nghieân cöùu cuûa Toå chöùc Y teá theá giôùi(WHO) taïi moät soá quoác gia ñang phaùt trieån cho thaáycoù moät tyû leä ñaùng keå khaùch haøng ñeán vôùi dòch vuïchaêm soùc söùc khoûe ban ñaàu do coù nhöõng roái loaïn veàtaâm thaàn3. Sau khi xem xeùt caùc nghieân cöùu dòch teãhoïc coù chaát löôïng treân theá giôùi, Fayyad vaø coäng söï2ñaõ ñöa ra keát luaän caùc nhoùm trieäu chöùng beänh hoïctaâm thaàn vaø tyû leä maéc caùc beänh naøy cuûa treû em vaøvò thaønh nieân ôû caùc nöôùc ñang phaùt trieån khaù gioángvôùi caùc nöôùc phöông Taây. Caùc soá lieäu nghieân cöùugaàn ñaây cho thaáy tyû leä vò thaønh nieân coù bieåu hieänroái loaïn taâm thaàn taïi Australia1vaø Myõ4laø khoaûngtreân 20%. Taïi Vieät Nam, keát quaû nghieân böôùc ñaàucuûa moät nghieân cöùu doïc taïi coäng ñoàng (thöïc hieän töønaêm 2000 ñeán 2015) ôû 5 tænh cho thaáy tyû leä treû 8 tuoåicoù trieäu chöùng roái loaïn haønh vi cuõng vaøo khoaûng20%5. Hieän nay caùc nghieân cöùu, ñaëc bieät laø nhöõngnghieân cöùu taïi coäng ñoàng ôû caùc nöôùc ñang phaùt trieånnoùi chung vaø ôû Vieät Nam noùi rieâng, coøn raát haïn cheá.Moät trong nhöõng khoù khaên lôùn ñoái vôùi caùc caùn boänghieân cöùu laø haàu heát caùc coâng cuï ñeå ño löôøng caùcvaán ñeà veà taâm thaàn nhö traàm caûm, lo aâu, roái loaïnhaønh vi,ñeàu ñöôïc phaùt trieån ôû caùc nöôùc phöông Taây.Trong khi ñoù, nieàm tin, giaù trò, ngoân ngöõ bieåu caûmvaø haønh vi cuûa con ngöôøi phuï thuoäc raát nhieàu vaøoheä thoáng, boái caûnh vaên hoùa nôi hoï sinh soáng6,7.ÔÛ nöôùc ta, cho ñeán nay chæ coù 2 nghieân cöùu coângboá keát quaû ñaùnh giaù coâng cuï saøng loïc caùc roái loaïntaâm thaàn ôû ngöôøi tröôûng thaønh taïi caùc cô sôû chaêmsoùc söùc khoûe ban ñaàu vaø coäng ñoàng coù teân goïi SRQ20 (Self-Reporting Questionnaire 20 items) cuûaWHO8,9. SRQ 20 goàm 20 tieåu muïc vôùi löïa choïn traûlôøi laø coù hoaëc khoâng, ñöôïc söû duïng ñeå chaån ñoaùn caùctrieäu chöùng roái loaïn taâm thaàn thoâng thöôøng, nhöngkhoâng giuùp caùn boä y teá phaân taùch ñoái töôïng thaønhcaùc nhoùm beänh taâm thaàn rieâng bieät. Caû 2 nghieân cöùuñaùnh giaù SRQ 20 ñeàu söû duïng phöông phaùp phaântích ROC (receiver operating characteristic) nhaèmxaùc ñònh ñieåm caét (cut-off point) cuûa thang ño saocho coù ñöôïc ñoä nhaïy vaø ñoä ñaëc hieäu toái öu. Hieänchöa coù nghieân cöùu naøo coâng boá keát quaû kieåm ñònhgiaù trò vaø ñoä tin caäy cuûa caùc coâng cuï ño löôøng roáiloaïn taâm thaàn cho ñoái töôïng vò thaønh nieân taïi coängñoàng ôû Vieät Nam.Vôùi ñoái töôïng vò thaønh nieân, traàm caûm vaø lo aâulaø nhöõng roái loaïn taâm thaàn thöôøng gaëp nhaát. Treântheá giôùi, trong caû lónh vöïc nghieân cöùu vaø thöïc haønhlaâm saøng, ngöôøi ta thöôøng söû duïng caùc boä caâu hoûi töïñieàn hoaëc phoûng vaán ñeå löôïng giaù caùc trieäu chöùngtraàm caûm vaø lo aâu cuûa vò thaønh nieân. Phöông phaùpnaøy ñôn giaûn, toán ít thôøi gian vaø thu thaäp ñöôïc nhöõngthoâng tin lieân quan ñeán caùc trieäu chöùng töø goùc ñoänhìn nhaän cuûa baûn thaân ñoái töôïng10. Trong soá caùcthang ño traàm caûm ñöôïc phaùt trieån ôû caùc nöôùcphöông Taây, thang ño cuûa Trung taâm nghieân cöùudòch teã hoïc (CES-D: The Center forEpidemiological Studies-Depression Scale) thuoäcTrung taâm phoøng ngöøa vaø kieåm soaùt beänh taät cuûaMyõ ñaõ ñöôïc kieåm ñònh vaø söû duïng raát nhieàu trongcaùc ñieàu tra coäng ñoàng vôùi ñoái töôïng vò thaønh nieânôû nhieàu quoác gia treân theá giôùi11,12. CES-D ñaùnh giaùmöùc ñoä traàm caûm trong 1 tuaàn tröôùc ñieàu tra, goàm20 tieåu muïc vôùi löïa choïn traû lôøi ôû 4 möùc (töø haàu heátcaû tuaàn, thöôøng xuyeân, thænh thoaûng, ñeán khoânghoaëc haàu nhö khoâng ngaøy naøo). Toång ñieåm cuûathang ño töø 0 ñeán 60 vôùi soá ñieåm caøng cao theå hieäntrieäu chöùng traàm caûm caøng naëng13.Treân theá giôùi, maëc duø coù nhieàu coâng cuï ñaùnh giaùcaùc nhoùm trieäu chöùng lo aâu ôû ngöôøi tröôûng thaønh,nhöng laïi khoâng coù nhieàu boä caâu hoûi coù ñoä tin caäycao duøng cho ñoái töôïng treû em vaø vò thaønh nieân. Quaxem xeùt taøi lieäu, chuùng toâi thaáy coù moät soá thang ñolo aâu duøng cho vò thaønh nieân ñaõ ñöôïc kieåm ñònhchaát löôïng vaø söû duïng nhieàu ôû moät soá quoác gia nhöSTAI (State-Trait Anxiety Inventory), RCMAS(Revised Childrens Manifest Anxiety Scale),MASC (Multidimensional Anxiety Scale forChildren), SCAS (Spence Childrens AnxietyScale)10. Tuy nhieân, caùc thang ño naøy thöôøng goàmraát nhieàu tieåu muïc (töø 40 ñeán 80), vì vaäy khoù khaûthi neáu söû duïng trong caùc nghieân cöùu coäng ñoàng caàn
  • | TOÅNG QUAN & NGHIEÂN CÖÙU |Taïp chí Y teá Coâng coäng, 1.2007, Soá 7 (7) 27ñoàng thôøi thu thaäp nhieàu thoâng tin khaùc nhau.Muïc tieâu cuûa nghieân cöùu naøy laø ñaùnh giaù giaù tròvaø ñoä tin caäy cuûa thang ño traàm caûm (CES-D), ñoàngthôøi xaây döïng vaø böôùc ñaàu ñaùnh giaù chaát löôïngthang ño nhoùm trieäu chöùng lo aâu ñeå coù theå söû duïngdeã daøng trong caùc nghieân cöùu coäng ñoàng vôùi ñoáitöôïng vò thaønh nieân ôû Vieät Nam.2. Phöông phaùp nghieân cöùuNghieân cöùu naøy laø moät phaàn cuûa nghieân cöùu thöûnghieäm naèm trong khuoân khoå cuûa moät cuoäc ñieàu tracoù qui moâ lôùn hôn ñeå ñaùnh giaù moät soá yeáu toá nguycô ñoái vôùi söùc khoûe theå chaát vaø taâm thaàn vò thaønhnieân.Maãu nghieân cöùuMaãu nghieân cöùu söû duïng ñeå ñaùnh giaù giaù trò vaøñoä tin caäy cuûa thang ño traàm caûm vaø lo aâu laø maãuthuaän tieän goàm toaøn boä caùc em hoïc sinh cuûa 1 lôùp7, 1 lôùp 9 vaø 1 lôùp 11 cuûa 1 tröôøng phoå thoâng cô sôûvaø 1 tröôøng Trung hoïc phoå thoâng ôû huyeän Chí Linh,Haûi Döông vaø quaän Ñoáng Ña, thaønh phoá Haø Noäi.Toång soá coù 6 lôùp cuûa 4 tröôøng ôû 2 quaän/huyeän thamgia goàm 326 em hoïc sinh. Soá phieáu hôïp leä söû duïngtrong phaân tích laø 299. Tyû leä traû lôøi laø 91,6%. Caùcem hoïc sinh tham gia coù ñoä tuoåi töø 13 ñeán 18 (tuoåitrung bình: 15,05, ñoä leäch chuaån: 1,64).Bieán nghieân cöùuTraàm caûm: baûn tieáng Anh goàm 20 tieåu muïc ñöôïcdòch xuoâi sang tieáng Vieät, sau ñoù baûn tieáng Vieätñöôïc moät ngöôøi söû duïng thaønh thaïo 2 thöù tieáng chöaheà bieát veà thang ño naøy dòch ngöôïc sang tieáng Anh.Baûn dòch tieáng Anh ñöôïc moät ngöôøi coù chuyeân moânvaø tieáng Anh laø tieáng meï ñeû kieåm tra ñeå ñaûm baûosöï nhaát quaùn veà yù nghóa cuûa baûn dòch vôùi baûn goác.Lo aâu: Chuùng toâi xaây döïng thang ño caùc trieäuchöùng lo aâu thoâng qua caùc böôùc sau:- Tham khaûo moät soá thang ño söû duïng phoå bieántreân theá giôùi vôùi ñoái töôïng treû em vaø vò thaønhnieân;- Böôùc ñaàu xaây döïng thang ño ngaén goïn goàm 16tieåu muïc baèng tieáng Anh, coù löïa choïn traû lôøi ôû 3möùc (khoâng bao giôø, thænh thoaûng, vaø thöôøngxuyeân). Theo gôïi yù cuûa Stallings vaø March14, caùccoâng cuï ño löôøng lo aâu toát caàn phaûi bao goàmñöôïc nhieàu nhoùm trieäu chöùng. Vì vaäy, 16 tieåumuïc naøy nhaèm saøng loïc moät soá nhoùm trieäu chöùnglo aâu thöôøng gaëp, ñoù laø: lo aâu khoâng coù nguyeânnhaân cuï theå, lo aâu khi bò taùch bieät, lo aâu tronggiao tieáp xaõ hoäi, lo aâu do caàu toaøn, vaø lo aâu theåhieän qua caùc trieäu chöùng veà theå chaát.- Laáy yù kieán goùp yù cuûa 2 chuyeân gia taâm lyù: Theophaân tích vaø ñeà nghò cuûa caùc chuyeân gia, thangño ñöôïc ruùt goïn coøn 14 tieåu muïc.- Baûn tieáng Anh goàm 14 tieåu muïc ñöôïc dòch xuoâivaø dòch ngöôïc nhö qui trình vôùi CES-D.Tröôùc khi tieán haønh nghieân cöùu, boä caâu hoûi ñaõñöôïc chænh söûa thoâng qua thöû nghieäm vôùi ñoái töôïnghoïc sinh vò thaønh nieân baèng caùch toå chöùc 8 cuoäc thaûoluaän nhoùm (moãi nhoùm goàm 6 ñeán 8 em) ñeå caùc emtrao ñoåi vaø goùp yù veà söï trong saùng, roõ raøng, deã hieåucuûa ngoân ngöõ vaø caùch thieát keá boä caâu hoûi.Thu thaäp soá lieäuNghieân cöùu ñöôïc söï cho pheùp cuûa phoøng giaùoduïc huyeän Chí Linh, Sôû giaùo duïc Haø Noäi vaø Bangiaùm hieäu cuûa caùc tröôøng ñöôïc môøi tham gia. Soálieäu thu thaäp baèng phöông phaùp söû duïng boä caâu hoûitöï ñieàn khuyeát danh. Caùc em hoïc sinh töï nguyeäntham gia nghieân cöùu traû lôøi caùc caâu hoûi taïi lôùp hoïcvôùi söï coù maët cuûa moät caùn boä nghieân cöùu. Thôøi gianñeå caùc em traû lôøi xong toaøn boä caâu hoûi (trong ñoù 2thang ño traàm caûm vaø lo aâu chæ laø moät phaàn cuûa boäcaâu hoûi) khoaûng 30-35 phuùt.Phaân tíchÑeå ñaùnh giaù tính giaù trò veà caáu truùc cuûa CES-D,chuùng toâi söû duïng phöông phaùp phaân tích yeáu toákhaúng ñònh (Confirmatory Factor Analysis-CFA)vôùi phaàn meàm AMOS (Analysis of MomentStructures) phieân baûn 5.0. Phöông phaùp phaân tíchnaøy nhaèm khaúng ñònh xem vôùi soá lieäu töø nghieân cöùunaøy, CES-D coù tuaân theo moâ hình goác goàm 4 yeáu toácuûa Radloff13hay khoâng. Boán yeáu toá cuûa CES-Dgoàm caûm giaùc chaùn naûn, thaát voïng (depressedaffect: 7 tieåu muïc), caûm xuùc tích cöïc, vui veû (posi-tive affect: 4 tieåu muïc); maát nguû vaø hoaït ñoäng ñìnhtreä (somatic and retarded activity: 7 tieåu muïc), vaømoái quan heä caù nhaân (interpersonal: 2 tieåu muïc).Vôùi thang ño lo aâu môùi ñöôïc xaây döïng, chuùng toâi aùpduïng phaân tích yeáu toá thaêm doø (Exploratory FactorAnalysis: EFA), söû duïng phaàn meàm SPSS(Statistical Package for Social Sciences) phieân baûn13 ñeå tìm hieåu moái quan heä cuûa caùc bieán trong thangño vaø böôùc ñaàu ñöa ra moâ hình caáu truùc caùc thaønhtoá. Ñeå ñaùnh giaù ñoä tin caäy veà söï nhaát quaùn beân trongcuûa 2 thang ño naøy, chuùng toâi duøng heä soá Cronbachs
  • 28 Taïp chí Y teá Coâng coäng, 1.2007, Soá 7 (7)| TOÅNG QUAN & NGHIEÂN CÖÙU |alpha vôùi phaàn meàm SPSS phieân baûn 13.3. Keát quaûÑoä tin caäyKeát quaû phaân tích cho thaáy caû 2 thang ño ñeàucho keát quaû toát veà ñoä tin caäy ñöôïc löôïng giaù baèngheä soá Cronbachs alpha (CES-D - 20 tieåu muïc coù =0,87 vaø thang ño lo aâu - 13 tieåu muïc coù = 0,82).Tính giaù trò veà caáu truùcKeát quaû phaân tích yeáu toá thaêm doø (EFA) cuûathang ño lo aâu:Chuùng toâi thöïc hieän EFA baèng caùch söû duïngphöông phaùp phaân tích thaønh toá chính (principalcomponent analysis-PCA). Tröôùc khi thöïc hieänPCA, boä soá lieäu ñöôïc kieåm tra tính phuø hôïp cho vieäcphaân tích yeáu toá, söû duïng giaù trò Kaiser-Mayer-Oklin vaø kieåm ñònh Bartlett. Giaù trò Kaiser-Mayer-Oklin baèng 0,82, vöôït xa giaù trò toái thieåu caàn phaûiñaït (0,60), vaø kieåm ñònh Bartlett coù yù nghóa thoángkeâ (p<.0001) theo nhö yeâu caàu15. Keát quaû naøy chopheùp thöïc hieän caùc böôùc phaân tích yeáu toá tieáp theo.Chuùng toâi löïa choïn soá löôïng thaønh toá/caáu phaànñöa vaøo phaân tích döïa treân bieåu ñoà caùc giaù trò rieâng.Ba thaønh toá ñöôïc choïn laàn löôït coù giaù trò rieâng (lôùnhôn 1 theo yeâu caàu) laø: 3,87, 1,49, 1,19 (giaù trò rieângcuûa moät thaønh toá theå hieän toång soá bieán thieân cuûathang ño giaûi thích bôûi yeáu toá ñoù). Baûng 1 toùm taétkeát quaû ma traän thaønh toá quay voøng (rotated com-ponent matrix).Khi ñaùnh giaù caùc thang ño môùi xaây döïng söûduïng EFA, caùc nhaø nghieân cöùu thöôøng choïn caùc tieåumuïc coù giaù trò töông quan trong ma traän thaønh toáquay voøng ít nhaát laø 0,30 ñeå hình thaønh neân caùcthaønh toá cuûa thang ño16. Trong nghieân cöùu naøychuùng toâi choïn nhöõng tieåu muïc coù giaù trò lieân quantreân 0,50 ñeå hình thaønh caùc thaønh toá cuûa thang ño loaâu. Trong soá 14 tieåu muïc, coù moät tieåu muïc coù giaù tròlieân quan nhoû hôn 0,30 trong caû 3 thaønh toá vì vaäychuùng toâi loaïi tieåu muïc naøy ra khoûi thang ño. Keátquaû ôû baûng 1 cho thaáy thaønh toá 1 (goàm 4 tieåu muïc),giaûi thích 18.1% söï bieán thieân, thaønh toá 2 (5 tieåumuïc) giaûi thích 17.4% söï bieán thieân vaø thaønh toá 3 (4tieåu muïc) giaûi thích 13.9% söï bieán thieân cuûa thangño lo aâu.Keát quaû phaân tích yeáu toá khaúng ñònh (CFA) cuûaCES-D:Baûng 2 toùm taét caùc chæ soá thoáng keâ quan troïngsöû duïng ñeå ñaùnh giaù söï phuø hôïp cuûa moâ hình phaântích. Hình 1 theå hieän moâ hình truøng khôùp cuûa nghieâncöùu naøy vôùi 4 thaønh toá goác cuûa CES-D.Moâ hình CFA ôû hình 1 vaø caùc chæ soá ôû baûng 2cho thaáy vôùi maãu nghieân cöùu laø ñoái töôïng vò thaønhnieân ôû Vieät Nam, moâ hình 4 thaønh toá cuûa CES-D ñaõñöôïc laëp laïi vaø phuø hôïp.4. Baøn luaänÑaây laø moät trong nhöõng nghieân cöùu ñaàu tieântrong lónh vöïc Y teá coâng coäng söû duïng EFA vaø CFAñeå böôùc ñaàu ñaùnh giaù giaù trò cuûa thang ño lo aâu môùixaây döïng vaø thang ño traàm caûm (CES-D), ñaõ ñöôïcsöû duïng roäng raõi trong caùc nghieân cöùu coäng ñoàngtreân theá giôùi, vôùi quaàn theå vò thaønh nieân ôû Vieät Nam.EFA laø phöông phaùp phaân tích ñöôïc thöôøng xuyeânsöû duïng trong quaù trình xaây döïng coâng cuï. EFA giuùpcaùc nhaø nghieân cöùu ruùt goïn soá tieåu muïc cuûa moätthang ño baèng caùch loaïi boû caùc tieåu muïc coù giaù tròlieân quan thaáp (low factor loading) vaø ñöa ra caâutruùc thaønh toá (factor structure) toái öu cuûa thang ño17.Thaønh toá/caáu phaàn1 2 3Sôï khi ôû moät mình trong nhaø .783 .052 .140Sôï khi phaûi nguû xa nhaø .752 .006 .292Sôï khi phaûi nguû moät mình .718 .148 -.047Deã daøng baät khoùc .532 .287 .102Khi sôï haõi caûm thaáy khoù thôû hoaëc toaùt moà hoâi .056 .683 .052Khoù ñi vaøo giaác nguû .010 .579 .194Coù nhöõng côn aùc moäng veà nhöõng ñieàu xaáu coùtheå xaûy ra vôùi baûn thaân vaø gia ñình.197 .547 .181Caûm thaáy sôï haõi maø khoâng coù nguyeân nhaân gì .124 .535 .066Raát deã giaät mình .384 .523 .101Boàn choàn, lo laéng khi phaûi tieáp xuùc vôùi ngöôøikhoâng quen.250 .233 .727Lo laéng seõ xaûy ra ñieàu gì xaáu(veà ñieàu xaáu seõ xaûy ra ).084 .306 .669Lo laéng lieäu mình coù laøm toát moïi vieäc khoâng .074 .371 .581Lo laéng lieäu mình coù ñöôïc nhö caùc baïn khaùckhoâng.055 .284 .538Tyû leä bieán thieân cuûa thang ño giaûi thích bôûimoãi thaønh toá18.1% 17.4% 13.9%Baûng 1. Keát quaû ma traän thaønh toá quay voøng cuûathang ño lo aâu⎟ χ2df GFI CFI NFI RMSEACES-D 1371* 164 .944 .912 .901 .053Baûng 2. Caùc chæ soá thoáng keâ CFA chính cuûa CES-D* p< 0.05CFI: chæ soá phuø hôïp so saùnh; GFI: Chæ soá phuø hôïp; NFI: Chæ soá phuøhôïp tieâu chuaån; RMSEA: Trung bình bình phöông sai soá.
  • | TOÅNG QUAN & NGHIEÂN CÖÙU |Taïp chí Y teá Coâng coäng, 1.2007, Soá 7 (7) 29Trong nghieân cöùu naøy chuùng toâi ñaõ loaïi 1 tieåu muïccoù giaù trò lieân quan nhoû hôn 0,30 trong caû 3 thaønh toácuûa thang ño lo aâu. Möôøi ba tieåu muïc coøn laïi ñeàu coùgiaù trò lieân quan cao treân 0,50 vaø phaân taùch roõ reätthaønh 3 thaønh toá. Chuùng toâi böôùc ñaàu ñaët teân cho 3thaønh toá cuûa thang ño lo aâu laàn löôït laø sôï haõi, caêngthaúng vaø boàn choàn, lo laéng. Ñoä tin caäy cuûa moãithaønh toá ñöôïc löôïng giaù baèng söï nhaát quaùn beân trongcho keát quaû ñaït yeâu caàu vôùi Cronbachs Alpha cuûa 3thaønh toá laàn löôït laø 0,72; 0,64; vaø 0,62. Heä soá tin caäycuûa thang ño lo aâu laø raát toát (= 0,82). Ñoä tin caäy cuûamoät thang ño ñöôïc ñaùnh giaù laø ñaït yeâu caàu neáu heäsoá tin caäy ñaït töø 0,6 trôû leân10.So vôùi caùc thang ño löôïng giaù vaán ñeà lo aâu ñaõñöôïc ñaùnh giaù vaø söû duïng nhieàu trong nghieân cöùucoäng ñoàng vôùi ñoái töôïng vò thaønh nieân nhö STAI,RCMAS, MASC, SCAS, vaø SAS-A (Social AnxietyScale for Adolescents)10,18, thang ño lo aâu do chuùngtoâi xaây döïng coù chaát löôïng töông ñöông veà ñoä tincaäy, giaù trò lieân quan cuûa caùc tieåu muïc vaø coù caáu truùcthaønh toá roõ raøng. Tuy nhieân, thang ño do chuùng toâixaây döïng coù soá löôïng tieåu muïc(13)ngaén goïn hônnhieàu so vôùi STAI, RCMAS, MASC vaø SCAS (40ñeán 80 tieåu muïc). Thang ño naøy laïi coù theå ño löôøngñoàng thôøi caùc nhoùm trieäu chöùng lo aâu khaùc nhau vìvaäy öu vieät hôn so vôùi SAS-A, chæ ñaùnh giaù caùc trieäuchöùng lo aâu xaõ hoäi. Chính vì vaäy qua ñaùnh giaù banñaàu, thang ño caùc trieäu chöùng lo aâu do chuùng toâi xaâydöïng ñaûm baûo giaù trò, ñoä tin caäy vaø khaù ngaén goïn,thuaän tieän cho söû duïng trong caùc nghieân cöùu coängñoàng lieân quan ñeán vaán ñeà söùc khoûe taâm thaàn vôùiñoái töôïng vò thaønh nieân ôû Vieät Nam.Vôùi thang ño traàm caûm chuùng toâi ñaõ söû duïngphöông phaùp CFA ñeå ñaùnh giaù tính giaù trò veà maëtcaáu truùc so vôùi moâ hình goác goàm 4 thaønh toá doRadloff13ñöa ra. Naêm chæ soá thöôøng ñöôïc caùc nhaønghieân cöùu söû duïng ñeá ñaùnh giaù söï phuø hôïp cuûa moâhình trong CFA ñoù laø χ2, CFI (comparative fitindex), GFI (goodness-of-fit index), NFI (normedfit index) vaø RMSEA (root mean square error ofapproximation). Tröôùc ñaây ngöôøi ta thöôøng söû duïngkieåm ñònh χ2laø moät trong nhöõng chæ soá ñeå ñaùnh giaùmöùc ñoä phuø hôïp toång theå cuûa moâ hình vaø moâ hìnhñöôïc cho laø phuø hôïp neáu χ2khoâng coù yù nghóa thoángkeâ. Tuy nhieân, do kieåm ñònh χ2raát nhaïy caûm vôùi côõmaãu, ñoä phöùc taïp cuûa moâ hình vaø phaân boá khoângchuaån cuûa boä soá lieäu neân chæ caàn coù söï khaùc bieät raátnhoû giöõa moâ hình goác vaø moâ hình phaân tích laø kieåmñònh naøy ñaõ cho keát quaû coù yù nghóa thoáng keâ. Vì vaäygaàn ñaây caùc nhaø nghieân cöùu ñaõ gôïi yù söû duïng moätnhoùm caùc chæ soá (CFI, GFI, NFI, vaø RMSEA) coù moáilieân quan vôùi kieåm ñònh χ2ñeå ñaùnh giaù möùc ñoä phuøhôïp cuûa thang ño vôùi moâ hình goác19. GFI so saùnh moâhình giaû ñònh vôùi khi khoâng coù moâ hình. GFI coù giaùtrò töø 0 ñeán 1 vôùi giaù trò caøng gaàn 1 theå hieän moâ hìnhgiaû ñònh caøng phuø hôïp. NFI löôïng hoùa söï bieán thieânvaø ñoàng bieán thieân ñöôïc giaûi thích bôûi moâ hình phaântích baèng caùch so saùnh söï phuø hôïp töông ñoái cuûa moâhình phaân tích vôùi moâ hình goác. NFI coù giaù trò töø 0ñeán 1. NFI caøng gaàn 1 cho thaáy söï ñoàng bieán thieâncaøng cao, neáu NFI lôùn hôn 0,90 coù theå khaúng ñònhmoâ hình raát phuø hôïp20. CFI löôïng giaù chaát löôïng phuøhôïp cuûa moâ hình, vôùi giaù trò lôùn hôn 0,90 cho thaáycoù söï phuø hôïp raát toát cuûa boä soá lieäu. Öu vieät cuûa CFIso vôùi kieåm ñònh χ2laø ôû choã noù khoâng phuï thuoäc vaøokích côõ maãu vaø coù tính ñeán ñoä phöùc taïp cuûa moâ hìnhphaân tích. RMSEA tính ñeán sai soá gaàn ñuùng trongquaàn theå, vôùi giaù trò nhoû hôn 0,05 theå hieän moâ hìnhraát phuø hôïp, töø 0,06 ñeán 0,08 chöùng toû moâ hình laøchaáp nhaän ñöôïc19.Trong nghieân cöùu naøy, keát quaû CFA cuûa CES-.43.43e17 Tieåu muïïc 17e3 Tieåu muïïc 3e6 Tieåu muïïc 6e9 Tieåu muïïc 9e10 Tieåu muïïc 10e14 Tieåu muïïc 14e18 Tieåu muïïc 18e4 Tieåu muïïc 4e8 Tieåu muïïc 8e12 Tieåu muïïc 12e16 Tieåu muïïc 16e1 Tieåu muïïc 1e2 Tieåu muïïc 2e5 Tieåu muïïc 5e7 Tieåu muïïc 7e11 Tieåu muïïc 11e13 Tieåu muïïc 13e20 Tieåu muïïc 20e15 Tieåu muïïc 15e19 Tieåu muïïc 19Chaùn naûn, thaát voïngCaûm xuùc, vui veûMaát nguû vaø hoaïtñoäng ñình treäMoái quan heä caù nhaân.ình 1. Moâ hình 4 thaønh toá cuûa CES-D vaø caùcgiaù trò lieân quan (vôùi ñoái töôïng laø vòthaønh nieân Vieät Nam)Ghi chuù: e1-e20 : Hai möôi tieåu muïc cuûa thang ño CES-D ñöôïcphaân tích döôùi daïng bieán aån.
  • 30 Taïp chí Y teá Coâng coäng, 1.2007, Soá 7 (7)| TOÅNG QUAN & NGHIEÂN CÖÙU |D cho thaáy 3 chæ soá (CFI, GFI, vaø NFI) ñeàu lôùn hôn0,90 vaø RMSEA baèng 0,053. So saùnh vôùi yeâu caàuñoái vôùi caùc chæ soá ñaùnh giaù möùc ñoä phuø hôïp cuûa moâhình trình baøy ôû treân, chuùng toâi coù theå keát luaän: moâhình goác goàm 4 yeáu toá cuûa Radloff13ñaõ ñöôïc laëp laïivôùi soá lieäu thu thaäp töø nhoùm vò thaønh nieân ôû VieätNam. Keát quaû CFA naøy khaù gioáng vôùi coâng boá cuûaCheung vaø Barley21khi ñaùnh giaù tính giaù trò cuûaCES-D duøng trong saøng loïc möùc ñoä traàm caûm vôùingöôøi tröôûng thaønh ôû Hoàng Koâng. Chæ soá tin caäy cuûaCES-D trong nghieân cöùu cuûa chuùng toâi laø raát toát ( =0,87) vaø töông töï caùc nghieân cöùu vôùi ñoái töôïng vòthaønh nieân ôû caùc quoác gia khaùc nhö Trung Quoác ñaïiluïc, Hoàng Koâng, Nhaät Baûn, Myõ11,12, 22.Nghieân cöùu naøy, söû duïng phöông phaùp phaân tíchtin caäy (EFA vaø CFA), ñaõ ñöa ra caùc keát quaû böôùcñaàu ñaùnh giaù giaù trò veà maët caáu truùc vaø ñoä tin caäylöôïng giaù baèng chæ soá nhaát quaùn beân trong cuûa thangño traàm caûm (CES-D) vaø thang ño trieäu chöùng lo aâudo chuùng toâi môùi xaây döïng. Keát quaû nghieân cöùu chothaáy caùc thang ño naøy coù theå söû duïng trong nghieâncöùu coäng ñoàng vôùi ñoái töôïng hoïc sinh vò thaønh nieânVieät Nam. Nghieân cöùu naøy ñaõ goùp phaàn cung caápcaùc coâng cuï ñaûm baûo chaát löôïng giuùp caùc caùn boänghieân cöùu thuaän lôïi hôn trong vieäc thöïc hieân caùcnghieân cöùu lieân quan ñeán söùc khoûe taâm thaàn vò thaønhnieân. Ñaëc bieät, söû duïng CES-D seõ giuùp chuùng ta coùtheå so saùnh keát quaû vôùi caùc nghieân cöùu khaùc treân theágiôùi hoaëc thöïc hieän caùc nghieân cöùu lieân quoác gia.Tuy nhieân, nghieân cöùu naøy cuõng coù moät soá ñieåmhaïn cheá sau ñaây. Tröôùc tieân, maãu nghieân cöùu laømaãu thuaän tieän vôùi ñoái töôïng hoïc sinh vò thaønh nieânvì vaäy caàn thaän troïng khi söû duïng caùc thang ño naøyvôùi ñoái töôïng vò thaønh nieân khaùc, ví duï nhoùm boû hoïc,nhoùm treû lang thang hoaëc coù caùc hoaøn caûnh ñaëc bieät.Thöù hai, baøi baùo naøy môùi trình baøy keát quaû kieåmñònh tính giaù trò veà caáu truùc nhöng chöa coù keát quaûkieåm ñònh tính giaù trò veà logíc (nomological validi-ty). Tuy nhieân, nhö ñaõ giôùi thieäu ôû phaàn ñaàu, baøi baùonaøy trình baøy moät phaàn keát quaû cuûa nghieân cöùu lôùnhôn nhaèm tìm hieåu veà söùc khoûe taâm thaàn vò thaønhnieân vaø moät soá yeáu toá nguy cô, vì vaäy chuùng toâi coùsoá lieäu cho thaáy 2 thang ño naøy ñaït keát quaû toát veàtính giaù trò logíc . Vì khuoân khoå baøi baùo coù haïn neânchuùng toâi khoâng trình baøy keát quaû theå hieän giaù tròveà logíc cuûa caùc thang ño naøy ôû ñaây. Thöù ba, nghieâncöùu naøy chæ ñaùnh giaù ñoä tin caäy cuûa thang ño döïatreân chæ soá veà söï nhaát quaùn beân trong, chöa ñaùnh giaùñoä tin caäy veà thöû nghieäm laïi. Trong töông lai chuùngta caàn tieáp tuïc thöïc hieän ñaùnh giaù naøy. Cuoái cuøng,nghieân cöùu naøy khoâng cho pheùp ñöa ra ñieåm caét cuûa2 thang ño nhaèm xaùc ñònh caùc ca beänh veà traàm caûmvaø lo aâu. Vì vaäy caàn tieán haønh nghieân cöùu tieáp theokeát hôïp söû duïng caùc thang ño naøy vaø chaån ñoaùn cuûachuyeân gia taâm thaàn ñeå xaùc ñònh ñieåm caét phuø hôïpvôùi boái caûnh vaø ñoái töôïng nghieân cöùu ôû Vieät Nam.
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