Validation of the Brazilian-Portuguese Version of a Short Questionnaire to Assess Knowledge in Cardiovascular Disease Patients (CADE-Q SV)

Ghisi, Gabriela Lima de Melo; Chaves, Gabriela S. S.; Loures, Jessica Blanco; Bonfim, Gabriela Moreira; Britto, Raquel

doi:10.5935/abc.20180169

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Original Article • Arq. Bras. Cardiol. 111 (6) • Dec 2018 • https://doi.org/10.5935/abc.20180169 copy

Validation of the Brazilian-Portuguese Version of a Short Questionnaire to Assess Knowledge in Cardiovascular Disease Patients (CADE-Q SV)

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background:

Patient education is an essential part of cardiovascular patients' care targeting self-management behavior to reduce risk factors and subsequent events. Herein, a short and reliable tool to assess patients' knowledge in Brazil is warranted.

Objectives:

To translate, culturally-adapt and psychometrically validate the Portuguese version of the Coronary Artery Disease Education Questionnaire Short Version (CADE-Q SV).

Methods:

The Portuguese CADE-Q SV - translated and culturally-adapted - was reviewed by five bilingual experts in cardiovascular disease. This version was then pre-tested in 21 patients, and clarity of items was checked using a Likert-type scale ranging from 1 = not clear to 10 = very clear. It was then psychometrically tested in 200 cardiovascular patients (41%women; mean age = 58.4 ± 11.6 years old). The internal consistency was assessed using Kuder-Richardson-20 (KR-20) and Cronbach's alpha, test-retest reliability through intraclass correlation coefficient (ICC), factor structure using confirmatory factor analysis, and construct validity regarding educational level, family income, and time of diagnosis.

Results:

All questions were considered clear by patients (clarity range:7.8-9.6). KR-20 was 0.70. All ICC values were > 0.70. Factor analysis revealed 6 factors, all internally consistent. Construct validity was supported by significant differences in total scores by educational level and family income (p < 0.001). The overall mean was 13.08 ± 2.61. The area with the highest knowledge was risk factors and the lowest was psychosocial risk.

Conclusions:

The Portuguese CADE-SV was demonstrated to have good validity and reliability. This tool can be applicable in clinical and research settings, assessing cardiovascular patients' knowledge as part of an education programming.

Keywords:
Cardiovascular Diseases; Coronary Artery Disease; Surveys and Questionnaires; Patient Education as Topic; Knowledge; Educational Status

Characteristic		CADE-Q SV Total Score
Sociodemographic			(mean ± SD)	p
Age, years (mean ± SD)		58.4 ± 11.6	-	-
Age dichotomous n (%)	Less than 65 years old	132 (66.0)	13.6 ± 2.4	0.001^† † p < 0.01,
	65 years old or older	68 (34.0)	12.2 ± 2.8
Sex n (%)	Male	118 (59.0)	13.3 ± 2.5	0.23
	Female	82 (41.0)	12.8 ± 2.8
Educational level n (%)	Never went to school	8 (4.0)	12.0 ± 3.2	< 0.001^‡ ‡ p < 0.001.
	Less than High School	128 (64.0)	12.5 ± 2.5
	High School	54 (27.0)	14.1 ± 2.4
	University	8 (4.0)	15.5 ± 1.2
	Post-graduation	2 (1.0)	17.0 ± 0.0
Monthly family income n (%)	No income	15 (7.5)	12.6 ± 1.8	0.04^* *()** p < 0.05,
	Less than 1 minimum salary	98 (49.0)	12.8 ± 2.7
	Between 1 and 3 minimum salaries	69 (34.5)	13.2 ± 2.6
	Between 4 and 5 minimum salaries	12 (6.0)	14.2 ± 2.0
	6 or more minimum salaries	4 (2.0)	16.0 ± 2.0
Clinical
Acute Cardiac Event n (%)	Acute Myocardial Infarction	113 (56.5)	13.5 ± 2.5	0.03^* *()** p < 0.05,
Comorbidities n (%)	Hypertension	179 (89.5)	13.1 ± 2.6	0.91
	Dyslipidemia	138 (69.0)	13.1 ± 2.5	0.81
	Stress	71 (35.5)	13.1 ± 2.5	0.81
	Peripheral Obstructive Arterial Disease	54 (27.0)	12.5 ± 3.0	0.06
	Diabetes Type II	53 (26.5)	13.4 ± 2.2	0.36
	Arrhythmia	51 (25.5)	12.4 ± 2.4	0.04^* *()** p < 0.05,
	Stable Apnea	42 (21.0)	12.9 ± 2.9	0.58
	Depression	41 (20.5)	12.8 ± 2.4	0.37
	Obesity	40 (20.0)	13.3 ± 2.6	0.65
	Unstable Angina	37 (18.5)	12.7 ± 2.2	0.55
	Smoking	19 (9.5)	14.4 ± 2.2	0.08
	Alcoholic behaviour	6 (3.0	14.5 ± 1.9	0.18
Time from diagnosis
Time from diagnosis, years (mean±SD)		8.6 ± 9.1	-	-
Time from diagnosis, n (%)	Less than 1 year	50 (25.0)	13.6 ± 2.4	0.23
	Between 1 and 5 years	44 (22.0)	12.6 ± 2.8
	Between 6 and 10 years	23 (11.5)	12.9 ± 2.6
	Between 11 and 15 years	25 (12.5)	13.9 ± 2.2
	More than 15 years	38 (19.0)	12.6 ± 2.6

Area	Item	Clarity^* * Clarity was assessed using a Likert-type scale ranging from 1 = not clear to 10 = very clear; Mean ± SD	Score Mean ± SD	Item completion rates (%)	ICC	Mean Score Per area
1 - Medical	1. Heart disease only happens in older people who smoke or have high cholesterol.	8.5 ± 1.9	0.73 ± 0.45	98.5	0.75	2.38 ± 0.76
	3. "Angina" is chest pain or discomfort in your arm, back or neck.	8.1 ± 3.0	0.75 ± 0.44	98.5	0.71
	6. Medications such as aspirin (ASA) help prevent blood clots from forming.	8.5 ± 2.6	0.86 ± 0.35	98.5	0.70
	11. "Statin" medications (such as atorvastatin and simvastatin) limit how much cholesterol your body absorbs from food.^† † item culturally adapted. Note: maximum score for item is 1 and for areas is 5.	8.8 ± 1.8	0.05 ± 0.21	98.5	0.72
2 - Risk Factors	2. Lifestyle changes such as healthy eating can lower your chances of developing heart disease.	9.1 ± 1.9	0.89 ± 0.32	98.0	0.80	2.95 ± 0.88
	12. To help control your blood pressure, eat less salt and exercise regularly.	9.5 ± 0.8	0.97 ± 0.16	98.5	0.83
	16. To control cholesterol, become a vegetarian and avoid eating eggs.	8.7 ± 1.5	0.51 ± 0.50	98.5	0.77
	18. You cannot prevent diabetes with exercise and healthy eating.	8.7 ± 2.1	0.58 ± 0.49	98.5	0.85
3 - Exercise	4. Resistance training (lifting weights or using elastic bands) can strengthen your muscles and help lower your blood sugar.	8.0 ± 2.5	0.63 ± 0.48	98.5	0.72	2.69 ± 1.01
	8. A warm-up before exercising raises your heart rate and lowers your chance of getting angina.	8.8 ± 1.6	0.63 ± 0.48	98.5	0.70
	13. If you get chest discomfort while walking, speed up to see if it goes away.	9.0 ± 1.6	0.86 ± 0.35	98.5	0.79
	17. You are exercising at the right level when your heart rate is in the target zone and you can still talk comfortably.	8.4 ± 2.4	0.57 ± 0.50	98.5	0.80
4 - Diet	5. Eating more meat and dairy products is a good way to add more fiber to your diet.	8.1 ± 2.2	0.47 ± 0.50	98.0	0.72	2.09 ± 0.84
	9. Prepared or processed foods, such as canned soup and bacon, usually have a lot of salt (sodium).	8.8 ± 2.1	0.90 ± 0.30	98.5	0.98
	14. Trans fat is an unhealthy type of fat that is often found in baked or fried foods.	7.8 ± 2.9	0.78 ± 0.41	98.5	0.74
	20. To help lower your blood pressure, eat healthy foods more often, such as vegetables, fruits, and whole grains.	9.6 ± 0.9	0.94 ± 0.24	98.5	0.94
5 - Psychosocial Risk	7. The only effective way to manage stress is to avoid people who cause unpleasant feelings.	8.2 ± 3.0	0.35 ± 0.48	98.5	0.77	1.97 ± 0.70
	10. Depression is common after a heart attack and increases the chance of having another heart attack.	8.5 ± 2.2	0.63 ± 0.48	98.0	0.78
	15. Sleep apnea (pauses in breathing during sleep) can increase your chance of having another heart attack.	8.1 ± 2.7	0.05 ± 0.21	98.5	0.77
	19. Stress increases your chance of having a heart attack as much as high blood pressure and diabetes.	9.1 ± 1.4	0.94 ± 0.23	98.5	0.72
Total		8.6 ± 3.2	13.08 ± 2.61	-	-	-

Items	Factor 1: Specific cases	Factor 2: Exercise	Factor 3: Diet	Factor 4: Medical	Factor 5: Risk factors	Factor 6: Psychosocial risk
10. Depression is common after a heart attack and increases the chance of having another heart attack.	0.47
11. "Statin" medications (such as atorvastatin and simvastatin) limit how much cholesterol your body absorbs from food.	0.39
15. Sleep apnea (pauses in breathing during sleep) can increase your chance of having another heart attack.	0.39
18. You cannot prevent diabetes with exercise and healthy eating.	0.31
4. Resistance training (lifting weights or using elastic bands) can strengthen your muscles and help lower your blood sugar.		0.33
8. A warm-up before exercising raises your heart rate and lowers your chance of getting angina.		0.46
13. If you get chest discomfort while walking, speed up to see if it goes away.		0.48
17. You are exercising at the right level when your heart rate is in the target zone and you can still talk comfortably.		0.47
5. Eating more meat and dairy products is a good way to add more fiber to your diet.			0.45
9. Prepared or processed foods, such as canned soup and bacon, usually have a lot of salt (sodium).			0.46
14. Trans fat is an unhealthy type of fat that is often found in baked or fried foods.			0.56
20. To help lower your blood pressure, eat healthy foods more often, such as vegetables, fruits, and whole grains.			0.38
1. Heart disease only happens in older people who smoke or have high cholesterol.				0.52
3. "Angina" is chest pain or discomfort in your arm, back or neck.				0.39
6. Medications such as aspirin (ASA) help prevent blood clots from forming.				0.44
2. Lifestyle changes such as healthy eating can lower your chances of developing heart disease.					0.30
12. To help control your blood pressure, eat less salt and exercise regularly.					0.56
16. To control cholesterol, become a vegetarian and avoid eating eggs.					0.34
7. The only effective way to manage stress is to avoid people who cause unpleasant feelings.						0.52
19. Stress increases your chance of having a heart attack as much as high blood pressure and diabetes.						0.32
Variance	17.3	11.1	9.4	8.2	6.9	6.6
Eigenvalues	3.3	1.6	1.5	1.2	1.2	1.1
Cronbach's Alpha	0.73	0.81	0.79	0.70	0.71	0.70

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[1] Mailing Address: Gabriela Lima de Melo Ghisi, 347 Rumsey Road Toronto ON M6S 5B7 - Toronto E-mail: gabriela.meloghisi@uhn.ca