Stroke Coaching Scale-11 items: Construction and psychometric validation

Abstract

Introduction

Patients who survive a stroke present difficulty in complying with secondary prevention. Therefore, new strategies, such as health coaching, are needed to evaluate these interventions in clinical practice.

Objective

To construct and validate the psychometric properties of a scale for evaluating health coaching in stroke patients.

Method

Observational study of the construction and validation of a Spanish assessment scale for health coaching in a prospective cohort of stroke patients. It was conducted in two phases: 1) construction and 2) validation of the scale. In the first phase, after evaluation by a group of experts, 11 items of the scale were constructed, with a Likert-type response option (0–10). In the second phase, validation and analysis of construct and reliability was carried out using the test-retest technique, with a difference of 3 weeks in a consecutive and prospective probability sample of 58 participants. In addition, a confirmatory factor analysis of the model was performed, and the following fit indices were obtained: comparative fit index (CFI), Tucker-Lewis index (TLI), and root mean square error of approximation (RMSEA) with a confidence interval (CI) of 95%.

Results

The pilot test applied to a sample of 14 subjects obtained good reliability (Cronbach's alpha = .806). In the retest the level of reliability was maintained (Cronbach's alpha = .813) and the intraclass correlation coefficient of all items showed reproducibility after three weeks from the first completion. The correlation between the dimensions was significant, although the correlation coefficient was not high. The following scale fit indices were also calculated: CFI = .933, TLI = .914 and RMSEA = .068 (95% CI.000–.119), which showed adequate values.

Conclusions

The Stroke Coaching Scale-11 items are a useful and valid instrument to assess health coaching in stroke patients.

Resumen

Introducción

Los pacientes que sobreviven a un ictus presentan dificultades para cumplir con la prevención secundaria. Por ello, son necesarias nuevas estrategias, como el coaching-salud, que permitan evaluar estas intervenciones en la práctica clínica.

Objetivo

Construir y validar las propiedades psicométricas de una escala de evaluación en coaching-saluden pacientes con ictus.

Método

Estudio observacional de construcción y validación de una escala de evaluación en castellano de coaching-salud en una cohorte prospectiva de pacientes con ictus. Se condujo en dos fases: 1) construcción y 2) validación de la escala. En la primera fase, tras la evaluación por un grupo de expertos, se conformaron 11 ítems de la escala, con opción de respuesta tipo Likert (0–10). En la segunda fase, se realizó la validación y análisis de constructo y fiabilidad, mediante la técnica test-retest, con una diferencia de 3 semanas en una muestra probabilística consecutiva y prospectiva a 58 participantes. Además, se realizó un análisis factorial confirmatorio del modelo y se obtuvieron los siguientes índices de ajuste: índice de ajuste comparativo (CFI), índice de Tucker-Lewis (TLI) y error cuadrático medio de aproximación (RMSEA) con un intervalo de confianza (IC) del 95%.

Resultados

La prueba piloto aplicada a una muestra de 14 participantes obtuvo una buena fiabilidad (Alfa de Cronbach = 0.806). En el retest el nivel de fiabilidad se mantuvo (Alfa de Cronbach = 0.813) y el coeficiente de correlación intraclase de todos los ítems mostró su reproducibilidad tras tres semanas desde la primera cumplimentación. La correlación entre las dimensiones fue significativa, a pesar de que el coeficiente de correlación no fue elevado. También se calcularon los siguientes índices de ajuste de la escala: CFI = 0.933, TLI = 0.914 y RMSEA = 0.068 (IC 95% 0.000−0.119), que mostraron valores adecuados.

Conclusiones

La Stroke Coaching Scale-11 ítems es un instrumento útil y válido para evaluar el coaching-salud en pacientes que han padecido un ictus.

Introduction

Stroke (CVA) has a high incidence, mortality, recurrence, and disability rate, severely affecting people's health.¹ Despite advances in pharmacological and neurointerventional treatments for CVA patients,¹ there is an increased risk of recurrent stroke and an increased risk of morbidity and mortality.²

Recurrence and health behaviours post stroke

The ARTPER study recently reported that a vascular event was the main type of recurrence after stroke, at a prevalence of 17%, followed by a myocardial infarction at 15%, and a mortality of 8% throughout the study.⁴ O'Donnell et al.⁵ suggested in an international study that ten modifiable risk factors are associated with 90% of stroke risk. Thus, correct adherence to medication and modification of modifiable risk factors (hypertension, dyslipidaemia, obesity, physical inactivity, diabetes, smoking, excessive alcohol consumption, diet, psychosocial stress, depression, sleep apnoea, etc.) play a key role in secondary stroke prevention.^6,7 Nevertheless, many stroke survivors have poor risk factor control and unhealthy lifestyle behaviours.^8,9

Different personal factors (depression, fatigue, pain, lack of motivation, lack of self-efficacy, negative beliefs, fear, etc.), family factors (lack of social support) and community factors (cost, access, etc.) act as barriers to behaviour changes and adherence to healthy lifestyles.^10,11

However, the family has been found to have a strong negative as well as positive influence on patients' beliefs and lifestyle changes post CVA.¹⁰. Physical, cognitive and emotional problems, such as mood disorders, are common in people after stroke and can negatively affect their ability to make lifestyle changes.^3,11 Low patient perception, knowledge and awareness of how lifestyle may contribute to stroke recurrence is also a frequent barrier.^3,11 Therefore, a patient-centred approach to secondary prevention can help a person with stroke become aware of their values and priorities, while understanding how their health behaviours act as facilitators or barriers to lifestyle change.³ Along the same lines, health coaching could be effective in promoting adherence to healthier lifestyles and improved management of the condition.¹²

Coaching on health and stroke

Aranda¹³ defines coaching as "a method for achieving results based on the accompaniment of a coach, which enables a person to work on the way he or she relates to him or herself to achieve a goal. This usually involves identifying their beliefs, language, values, emotions, priorities, choices about the goal and their experience with it. It generates awareness, learning, and different goal-oriented action and thus develops the person's capacity to cope with their challenges" (p.28). In coaching for stroke survivors, the following should be established as a health goal: continuous learning about secondary prevention education, use of self-management techniques, face-to-face or telephone follow-up, medication management, and prevention of complications.¹⁴

To achieve behavioural change goals in health coaching, the starting point and the goal to be achieved need to be established.^12,13 Any coaching process requires validated measurement methods that help the person become aware of their current situation, and monitor progress in achieving the goals set.^13,14 However, there are few validated health-coaching tools available for use in clinical practice.

To date, there is no known health coaching tool for stroke patients. Therefore, the aim of the present study was to construct a health coaching assessment scale and to validate its psychometric properties in stroke survivors.

Procedure

Phase I. Construction of the scale

A literature review was conducted on secondary stroke prevention and health behaviours that act as facilitators or barriers to lifestyle change.^3,7–11 A group of four experts was then consulted to evaluate a first proposal of possible constructs for the final repertoire of indicators (a neurologist, two nurses with expertise in stroke patient management, and a nurse expert in coaching). The result of this phase was a list of constructs that were taken as a starting point to develop the content of the items: sleep and rest, nutrition and weight, social relationships, medication, quality of life, emotional well-being, self-image, pain and fatigue, analytical parameters, toxic habits, and physical activity. Twenty items were drafted and considered to construct the questionnaire. Subsequently, the content and wording of the items were revised according to the comments of the experts, which allowed the items to be combined and reduced to 11.

The scale consisted of 11 items that were written in the second person and in Spanish. As a response, a 10-point Likert-type score was established for each item, ranging from (0 = the patient is not satisfied to 10 = the patient is totally satisfied).

A pilot test of the scale was conducted to test the intelligibility and clarity of the set of items. It was distributed to a sample of 14 stroke survivors selected by snowball sampling. The content and wording of the items were then reviewed, with no need for modifications or misunderstandings of response.

Phase II. Validation of the scale

Finally, the scale was validated between June 2020 and May 2021, by consecutive and prospective probability sampling of stroke survivors attended by the neurovascular nursing clinic of the Hospital de Tortosa Verge de la Cinta (HTVC), Tarragona, Spain. We included men and women aged ≥ 18 years, with a diagnosis of stroke confirmed ≥ 2 months, presenting ≥ 1 modifiable risk factor, without severe neurological involvement (modified Rankin scale score of ≤ 2),¹⁵ who could read and write in Spanish, and had signed their informed consent for the study. All patients diagnosed with aphasia, cognitive impairment and with a diagnosis of another condition that could interfere with the execution of the study (psychiatric disorder, active cancer, etc.) were excluded.

The recommendations of Norman and Streiner were followed to calculate the sample size, who consider that there should be between 5 and 20 subjects for each item making up the scale. Therefore, the study sample comprised 58 stroke survivors who met the selection criteria.

The scale was administered by a nurse who was an expert in the management of patients with cerebral vascular disease, in the neurovascular clinic, by means of a clinical interview. Once the definitive version of the scale had been administered, the psychometric properties of reliability and validity were analysed. Content validity was determined to consolidate the various areas related to sleep and rest, nutrition and weight, social relationships, medication, quality of life, emotional well-being, self-image, pain and fatigue, analytical parameters, toxic habits, and physical activity. Currently, there is no measurement instrument in the Spanish language to help a person become aware of health behaviours through a coaching intervention. Therefore, criterion validity could not be analysed using a gold standard.

Ethical considerations

The study was approved by the Ethics and Drug Research Committee of the Institut d'Investigació Sanitària Pere Virgili (CEIm-IISPV) with code 174/2019. All procedures were performed in compliance with the principles of the 1964 Declaration of Helsinki and its subsequent modifications.¹⁷ All the participants signed the informed consent form.

Data analysis

The internal consistency of the scale was analysed by calculating reliability. Cronbach's alpha coefficient was used and a result between .70 and .90 was considered acceptable, while a value below .70 indicates a poor relationship between the items and a result above .90 is considered a reiteration of the items.¹⁶ In addition, the test-retest reliability and temporal stability of the scale were assessed, obtained after administering the questionnaire to the same population on two different occasions after a period of three weeks from the first completion, establishing an acceptable level of reliability with results above .70 in the test-retest correlation coefficient. Finally, the median score for each item of the instrument was calculated, as well as the 25th and 75th percentiles. Confirmatory factor analysis of the model showed the following fit indices: comparative fit index (CFI), Tucker-Lewis index (TLI), and root mean square error of approximation (RMSEA) with a confidence interval (CI) of 95%. The percentage of variance explained by each of the 11 items was also calculated.

Analyses were performed using the SPSS statistical package, version 26.0, for Windows (IBM, Armonk, NY, USA) and R statistical software (R Core Team, 2019, R Foundation for Statistical Computing Vienna, Austria).

Results and discussion

A Spanish-language coaching-health assessment scale was constructed in the present study and its psychometric properties were validated in a population of stroke survivors.

The pilot test conducted with 14 individuals showed that the scale had a good level of reliability (Cronbach's alpha = .806). Moreover, no problems of comprehension or understanding of the different questions by the individuals were found during the pilot test.

Regarding the sociodemographic characteristics of the participants, the mean age was 65.5 years, 77.6% were male, and 62.1% had basic education. Regarding clinical characteristics, the majority stroke aetiology according to TOAST¹⁸ criteria was atherothrombotic (44.8%), followed by cardioembolic (22.4%), and undetermined (17.2%); the most predominant risk factors were hypertension (82.7%), dyslipidaemia (70.7%), and obesity (53.4%) (Table 1).

Table 1.

Sociodemographic and clinical characteristics of the patients (n = 58).

Age, mean (SD)	65.5 (10.43)
Sex, n (%)
Male	45 (77.6)
Female	13 (22.4)
Level of education, n (%)
No education	2 (3.4)
Basic education	36 (62.1)
Vocational education	18 (31.0)
University education	2 (3.4)
Aetiology of stroke, n (%)
Cardioembolic ischaemic stroke	13 (22.4)
Atherothrombotic ischaemic stroke	26 (44.8)
Lacunar ischaemic stroke	8 (13.8)
Indeterminate ischaemic stroke	10 (17,2)
Ischaemic stroke of unusual cause	1 (1,7)
Risk factors, n (%)
HTN	48 (82,7)
Smoking	17 (29,3)
Dyslipidaemia	41 (70,7)
Obesity	31 (53,4)
Diabetes mellitus	26 (44,8)
Heart disease	16 (27,6)
Sedentarism	1 (1,7)
Alcohol	5 (8,6)

Quantitative variables (age) are described by mean and standard deviation (SD), while qualitative variables (sex, level of education, stroke aetiology, and risk factors) are described in absolute frequencies and percentages.

The calculation of the reliability of the scale indicated an acceptable internal consistency (Cronbach's alpha = .668), reflecting that the 11 items of the questionnaire are consistent with each other.

The items with the highest scores and, therefore, the highest degree of patient satisfaction was awarded to those referring to the areas of medication and toxic habits. In contrast, the items with the lowest scores, i.e., the lowest degree of patient satisfaction, were those relating to sleep and rest, and to pain and fatigue (Table 2).

Table 2.

Questions included in the questionnaire that make up the 11 items of the scale and median score for each (n = 58).

Functional questions of the Stroke Coaching Scale-11 items	Score
Item 1: sleep and rest
Do you think you get the sleep and rest you need?	7 [5–8]
Item 2: nutrition and weight
Do you think that you eat according to your weight?	8 [5–8]
Item 3: social relationships
Do you think you take care of your relationships with others?	9 [8–10]
Item 4: medication
Do you think you take your medication as prescribed?	10 [10–10]
Item 5: quality of life
Are you satisfied with your quality of life?	8.5 [6–10]
Item 6: emotional wellbeing
Are you cheerful and happy most of the time?	8 [6–10]
Item 7: self-image
Do you take care of yourself and like how you look in the mirror?	8 [6–10]
Item 8: pain and fatigue
Are you in pain or tired when you undertake your daily activities?	7 [5–9]
Item 9: analytical parameters
Do you think your blood sugar, blood pressure, etc. are well controlled.?	8 [6–10]
Item 10: toxic habits
Do you think you use a normal amount of cigarettes, alcoholic drinks, or some drugs?	10 [8–10]
Item 11: physical activity
Are you satisfied with your weekly exercise or physical activity?	8 [5–10]
Total score	87 [77.5−94]

Scores refer to median and 25th and 75th percentiles.

Analysis of the 11 items shows a highly significant intraclass correlation coefficient (ICC), ranging from 0 to 110 points. The median score obtained in its validation was 87 points, with an interquartile range of 16.75 points. The reliability of the scale was recalculated after the retest, which showed that the internal consistency remained at a good level (Cronbach's alpha = .813).

Moreover, the ICC of all the items between test and retest showed reproducibility after three weeks from the first application (Table 3).

Table 3.

Intraclass correlation coefficient (ICC), confidence interval and p-value in test-retest (n = 58).

Stroke Coaching Scale-11 items	ICC	95% confidence interval	p
1. Sleep and rest item	.669	.441−.804	<.001
2. Nutrition and weight item	.571	.275−.746	.001
3. Social relationships item	.523	.195−.718	.003
4. Medication item	.639	.391−.787	<.001
5. Quality of life item	.799	.660−.881	<.001
6. Emotional wellbeing item	.857	.759−.916	<.001
7. Self-image item	.752	.581−.853	<.001
8. Pain and fatigue item	.493	.143−.700	.006
9. Analytical parameter item	.677	.451−.810	<.001
10. Toxic habits item	.745	.570−.849	<.001
11. Physical activity item	.752	.579−.854	<.001
Total score	.874	.784−.926	<.001

This scale, the Stroke Coaching Scale-11 items, consists of a categorical Likert-type score, whereby the person is asked to rate each area from 0 to 10, 0 being not at all satisfied and 10 being totally satisfied. These 11 items represent sleep and rest, nutrition and weight, social relationships, medication, quality of life, emotional well-being, personal image, pain and fatigue, analytical parameters, toxic habits, and physical activity. The parameterisation of each item of the scale allows it to be easily completed; furthermore, it does not require prior training to be administered. The instrument takes between 5 and 10 min to complete and therefore is feasible for use in clinical practice by nurses or other health professionals who want to use health coaching to improve their patients’ therapeutic adherence and healthy lifestyles, and measure their results.

Based on the results, the 11 items were grouped into two dimensions; dimension 1: self-perception (items 3, 5, 6, 7 and 8); dimension 2: health behaviours (items 1, 2, 4, 9, 10 and 11). Two dimensions were extracted from the Stroke Coaching Scale-11 items. Calculation of Cronbach's alpha for each of the dimensions yielded the following (Cronbach's alpha dimension 1 = .786; Cronbach's alpha dimension 2 = .549).

The first dimension focuses on self-perception of life. The 5 items forming this dimension pertain to factors of social relationships, quality of life, emotional well-being, self-image, and pain and fatigue. Studies have shown that there are multiple factors that influence the quality of life of people with stroke, at the clinical and symptomatological¹⁹ as well as psychological²⁰ level. Pain and fatigue is a common complication after stroke and is associated with quality of life,²¹ as well as being associated with depression and increased mortality.²² Emotional wellbeing, social relationships and social support are also associated with improved outcomes and quality of life in these patients.^23–25 Likewise, people with disabilities may have an altered perception of their self-image, and consequently influence their perception of their own body image, their satisfaction, as well as health behaviours.²⁶

The second dimension refers to health behaviours. The six items it covers are sleep and rest, nutrition and weight, medication, analytical parameters, toxic habits, and physical activity. The literature argues that health behaviours can reduce the risk of stroke, and poor nutrition and sleep disorders have been associated with severe neurological consequences.^27,28 Poor adherence to medication, drug use, and a sedentary lifestyle are associated with poor control of laboratory parameters and therefore with a risk of vascular recurrence.^23,29

The correlation between the dimensions was significant, although the correlation coefficient was not high (Table 4). The following scale fit indices were also calculated: CFI = .933, TLI = .914 and RMSEA = .068 (CI 95%: .000–.119), which showed adequate values. The graphical representation of the model and the percentage of variance explained by each of the 11 items are shown in Fig. 1.

Table 4.

Spearman correlation (ρ) between the proposed dimensions and p-value.

Stroke Coaching Scale-11 items	Dimension 1	Dimension 2
Dimension 1.
Self-perception	ρ	1000	.481
Items 3, 5, 6, 7 y 8	p-value	–	<.001
Dimension 2.
Health behaviours	ρ	.481	1000
Items 1, 2, 4, 9, 10 y 11	p-value	<.001	–

Figure 1.

Graphical representation of the factor analysis model, percentage of variance explained by each of the items comprising the two dimensions of the Stroke Coaching Scale-11, and Cronbach's alpha for each dimension.

D.1: dimension 1 (self-perception); D2: dimension 2 (health behaviours).

We recommend that, after the scale has been completed, the nurse-coach or the health professional using the scale should ask the patient the factor in which they would like to start making changes in their lifestyle; it is recommended to start with the one they consider easiest. And then a health goal needs to be set. The PRAMPE technique can be used for this purpose: Positive-Relevant-Agreed-Measurable-Personal-Specific,³⁰ or the SMART technique: Specific-Measurable-Attainable-Revelant-Time-bound.³¹ In addition, it is important to understand how motivated the person is to achieve the goal set by asking about their self-confidence to carry out actions and the importance of change.³⁰

There is currently no validated coaching scale available in Spanish. It is important to have validated coaching instruments, especially for patients who have suffered a stroke, since good control of cardiovascular risk factors directly influences the risk of the onset and recurrence of a new vascular episode.^32,33 Thus, this instrument is proposed as a necessity in health promotion, both in primary care and hospital settings, where it can be used to promote and maintain correct management of cardiovascular risk factors in stroke patients. Similarly, the validated Stroke Coaching Scale-11 items can be used in highly rigorous research to encourage self-reflection and self-assessment in stroke survivors wanting to make lifestyle changes through health coaching. It is worth noting that a recent meta-analysis revealed a significant improvement in quality of life, activities of daily living, and a reduction in depression at three months in stroke survivors who had received health coaching.¹⁴ The results indicate that this instrument helps the person to reflect on their health behaviours, detecting the weak and strong aspects of each area. Considering that once patients become aware that they are willing to change their behaviours, they may be less resistant to change and begin to discuss strategies for adopting healthier lifestyles.⁴

The main limitation of this study is that its sample was from a hospital in the province of Tarragona, and therefore cannot be representative as it does not reflect the characteristics of the Spanish population. However, evaluation of the test and retest scale in the same individuals with a difference of three weeks allowed us to control some variables, including temporal stability. However, the scale was administered by interview, and therefore there may have been some interview bias. In the future, a study where the scale is self-administered is recommended.

Conclusions

The Stroke Coaching Scale-11 items for stroke survivors has favourable psychometric properties. The internal consistency of both the total scale and its dimensions (self-perception and health behaviours) is adequate and acceptable. The construction of this coaching scale can help quantify and provide health coaching techniques. The psychometric indicators, both for the dimensions and for the scale as a whole, reveal that it is a reliable and valid measurement instrument for conducting research studies on coaching in stroke survivors who want to change their lifestyle to improve their health. It may also be valid for measuring the pre- and post-intervention outcome of individual coaching sessions. This quantitative measurement instrument may be transferable for use in other diseases with modifiable risk factors, although a psychometric analysis in these populations would be necessary beforehand. However, a longitudinal study is needed to assess the implementation of the scale in individual coaching sessions.

Intellectual property registration

The Stroke Coaching Scale-11 items is registered as a work of intellectual property certified by Safecreative (Global Copyright Registry), which has all the effects of protection and defence of its rights.

Funding

First prize for the best Research Project of the Spanish Society of Neurological Nursing (SEDENE), November 2019.

Conflict of interests

The authors have no conflict of interests to declare.

Acknowledgements

We would like to thank the professionals of the neurology service of the Hospital de Tortosa Verge de la Cinta, and to the patients for their time and contribution to the study.