Validation of the Chinese Translated Activities-Specific Balance Confidence Scale

Article Outline

• Abstract
• Methods
  • Phase 1
  • Phase 2
  • Data Analysis
• Results
  • Translation and Content Equivalence of ABC-C Scale
  • Reliability of the ABC-C Scale
  • Validity of the ABC-C Scale
  • Self-Perceived Balance Confidence of Older Adults in Hong Kong
• Discussion
• Conclusions
• Acknowledgment
• APPENDIX 1. Chinese Version of Activities-Specific Balance Confidence Scale
• References
• Copyright

Abstract 

Mak MK, Lau AL, Law FS, Cheung CC, Wong IS. Validation of the Chinese translated Activities-Specific Balance Confidence scale.

Objectives

To translate contents of the Activities-Specific Balance Confidence (ABC) scale into Chinese (Cantonese), to examine the psychometric properties (internal reliability and validity) of this scale for use with Chinese older adults in Hong Kong, and to determine the level of self-perceived balance confidence of this population.

Design

A 2-phase exploratory study: formative qualitative research and a cross-sectional survey to establish the psychometric properties of the Chinese translated ABC (ABC-C) scale.

Setting

Community based.

Participants

One hundred older community-dwelling subjects.

Interventions

Not applicable.

Main Outcome Measure

Measurement of perceived level of confidence in maintaining balance using the ABC-C scale. This instrument contains 16 items on indoor and outdoor activities requiring different levels of balance function.

Results

Four of the 16 ABC-C scale items had to be modified to achieve content equivalence and cultural relevance to Hong Kong. Final test items of this scale showed high internal consistency with a Cronbach α coefficient of .97. The instrument was found to have excellent test-retest and very good interrater reliability with intraclass coefficients of .99 and .85, respectively. Results of a factor analysis conducted on the scale showed evidence of a coherent 1-domain structure. The mean perceived balance confidence level ± standard deviation of 100 community-dwelling older adults in Hong Kong, performed by using the ABC-C scale, was 71.6±23.7.

Conclusions

Results of the present study verified that the ABC-C scale is a culturally relevant, valid, and reliable tool for measuring self-perceived balance confidence in Chinese older adults. These were reflected in very good to excellent internal consistency of items, test-retest and interrater reliability, and construct validity shown.

Key Words: Accidental falls, Balance, Elderly, Fear, Rehabilitation

FALLS OCCUR COMMONLY IN approximately one third of community-dwelling elderly people each year.¹, ², ³ In older people, falls can cause physical injuries such as fractures and/or head injuries leading to restricted mobility, decreased performance in activities of daily living, and increased risk of placement in a nursing home.⁴, ⁵ Falls may also result in negative psychologic consequences such as fear of falling, which has been reported to occur in 29% to 92% of elderly people with a history of falls.⁶, ⁷ The wide variation could be attributable to differences in the methods used to measure fear of falling.⁸ Although having some level of fear is reasonable and can promote effective coping skills in fall prevention, excess fear may compromise physical, psychosocial, and functional well-being.⁹, ¹⁰, ¹¹ The debilitating physical consequences of fear of falling are self-induced restriction of activities, physical deconditioning, and functional incapacity. Psychosocial consequences include increased risk of social isolation, damage to social identity, depression, anxiety, and poor quality of life.⁷, ¹², ¹³ Therefore, fear of falling is a construct that needs to be assessed, clearly understood, and managed in its own right.¹⁴ Early identification and accurate measurement of fear of falling are 2 very important aspects of fall management.

A common means of measuring fear of falling is to assess self-efficacy related to falls. This essentially involves assessing a person’s perception of their capabilities to perform specific activities without falling.¹⁵, ¹⁶ Prior work¹⁷, ¹⁸, ¹⁹ has shown that a higher level of fall efficacy or a lower level of fear of falling is associated with better functional outcomes such as independent performances in activities of daily living. The Fall Efficacy Scale (FES) is the first standardized measure developed to document fall efficacy related to performances of daily functional activities by older adults.²⁰ This instrument was reported to have good test-retest reliability and high internal consistency.²¹ However, FES measures fall efficacy restricted to simple indoor activities, which fails to provide information on perceived performances related to more complex functional activities. The FES also tended to show a ceiling effect with higher level functioning people living in the community.²¹

An alternative we proposed is the Activities-Specific Balance Confidence (ABC) scale, which was developed to assess subjective balance confidence in ambulatory, community-dwelling older people.²¹ Based on a psychologic concept relatively similar to fall efficacy, the ABC scale assesses a person’s self perceived level of confidence in his/her ability to maintain balance required for performing daily functional activities.²² This instrument contains 16 items, each representing a range of indoor and outdoor activities that require varying degrees of balance function. Respondents are asked to indicate their level of confidence in performing each activity by using a 0% to 100% scale distribution. The ABC scale has been shown to have good psychometric properties with high internal consistency (Cronbach α=.96), excellent test-retest reliability (r=.92), good convergent validity with the physical activities subscale of the physical self-efficacy scale (r=.63), and discriminant validity.²¹ This instrument has already been modified for use with an older British population showing good internal consistency and test-retest reliability.²³ However, the scale has neither been translated nor been validated for use with Chinese populations. Cultural differences between Western and Chinese societies may influence elderly people’s conceptualization of “self-perceived balance confidence” and cultural relevance of activities assessed by the instrument. The aims of this study were (1) to translate the contents of the ABC scale into Chinese (Cantonese) to achieve content equivalence, (2) to examine the psychometric properties of the Chinese translated ABC scale (ABC-C) with Chinese older adults in Hong Kong including internal reliability (internal consistency, test-retest, interrater reliability) and internal validity (construct), and (3) to determine the level of self-perceived balance confidence of this population.

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Methods 

To achieve the research objectives, the study was conducted in 2 phases. Phase 1 translated contents of the ABC scale into Chinese (ABC-C) and examined content equivalence. Phase 2 involved validation of the ABC-C scale for use with the Chinese elderly population in Hong Kong.

Phase 1 

The original ABC description was first examined for content equivalence. This included (1) conceptual equivalence, which refers to the sameness of concept or meaning underpinning the test questions asked in the instrument between the original and translated languages; (2) semantic equivalence, which refers to the denotative and connotative sameness of words between the 2 language versions (that is, the explicit meaning of the translated test items as words and their concurrence with the original source language); and (3) technical equivalence, which examines the technical features of language and their relation to the sociocultural context, including fluency, clarity, and comprehensibility.²⁴ Only items of the scale that were considered to have shown inadequate conceptual and cultural relevance were subjected to a further review by an expert panel. The panel comprised 10 physiotherapists who had more than 10 years of work experience including 3 or more years working with older adults. The panel members were asked to rate the cultural relevance of “activities” assessed in the test items of the ABC scale to Hong Kong. This involved the use of a 5-point rating scale, ranging from very irrelevant (1) to very relevant (5). For an activity rated “culturally irrelevant,” the judges were asked to justify and suggest an alternative culturally relevant activity.

The next step involved a forward translation of all test items (including revised ones from the previous step) and testing instructions of the ABC scale from original English language into Chinese (colloquial Cantonese). The Chinese-translated contents were then translated into English (backward translation) to ascertain that their original meanings were retained. This process involved 2 independent professional translators who were briefed thoroughly on the purpose and function of the scale so to facilitate translation of contents that would be more “meaning” rather than “semantic” driven. The English-translated contents were then compared by the investigators with the original English-version ABC scale to verify they had achieved conceptual, semantic, and technical equivalence. The final ABC-C scale was pilot tested with 3 older adults to ascertain its fluency, clarity, and comprehensibility.

Phase 2 

To validate the ABC-C scale, 100 Cantonese-speaking community-dwellers were recruited from 5 community-based elderly centers. Inclusion criteria included aged 65 years and older and independence in indoor ambulation with or without aids. People who had communication deficits and cognitive impairment (Mini-Mental State Examination score <18) were excluded. Table 1 shows the sociodemographic and physical health characteristics of the subjects. The cohort had a mean age of 77.2 years, and 56% were women. The majority (90%) did not require physical assistance to walk outdoors, and only 13% had a history of at least 1 fall in the past 6 months. A large number (86%) routinely exercised at least 3 times per week. Informed consent was obtained from each subject in accordance with the 1964 Declaration of Helsinki, and the study commenced after approval from the local ethics committees. All subjects were assessed by using the ABC-C scale in an individual face-to-face interview. Fifty-six percent (n=56) were randomly selected by drawing lots for reassessment on the same instrument after 2 weeks. Of the 56 subjects, 44.6% (n=25) were reassessed to establish test-retest reliability, whereas the remaining (n=31) were to determine interrater reliability of the ABC-C scale (see table 1). A 2-week interval was used to minimize chances of subjects’ recall of contents from the previous assessment. This period was also considered optimal for avoiding potential occurrences of significant events or changes in their life circumstances that could also impact on their self-perceived balance confidence ratings.²⁵

Table 1. Characteristics of Study Sample

Characteristics		Frequency (%)
		Main Study (N=100)	Test-Retest Reliability (n=25)	Interrater Reliability (n=31)
Age (y)	65–74	34	36	35
	75−84	55	60	52
	≥85	11	4	13
Sex	Female	57	60	68
Marital status	Single	14	20	16
	Married	37	44	26
	Widowed	48	36	55
	Divorced	1	0	3
Use of walking aids indoor	No	83	72	87
	Yes	17	28	13
Use of walking aids outdoor	No	63	52	71
	Yes	37	48	29
Need assistance to walk outdoor		10	16	6
Fall history in past 6mo		13	20	13
Habit of regular	≥3	86	72	90
exercise (times/	<3	14	28	10
wk)

Data Analysis 

All data collected were analyzed by using statistics software SPSS.^a In phase 1, to determine whether an item (activity) was culturally relevant, mode calculations for each item and an interjudge percentage agreement were adopted. For an item to be considered “culturally relevant,” it had to be rated 4 (relevant) or 5 (highly relevant) with a 70% agreement achieved among panel experts. An item that failed to fulfill these criteria would require modification. In phase 2, internal consistency of the 16 item ABC-C scale was determined by using the Cronbach α coefficient and item total correlations. Both test-retest and interrater reliabilities were established using the intraclass correlation (ICC) 1-way random model. Exploratory factor analysis was used to examine the structural coherence of the scale. Descriptive statistical analysis was performed to identify the level of self-perceived balance confidence of subjects.

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Results 

Translation and Content Equivalence of ABC-C Scale 

Twelve of the 16 items on the ABC-C scale were found to be culturally relevant after reviews conducted by the expert panel and investigators of the study. The 4 items that were judged “culturally irrelevant” by the expert panel achieved a low interjudge agreement of 0% to 50% on 4 (relevant) and 5 (highly relevant) ratings assigned to these items. They comprised activities that all required some degree of dynamic balance (table 2, left-hand column). These activities were considered inappropriate because of considered differences in physical living environment, mode of transportation, and climate between Hong Kong and the ABC scale’s place of origin, Canada. Specifically, in the original wording of item 3 concerned with the perceived level of competence a person has in bending and picking up a commonly used item (slipper) from the floor, the phrase “…from the front of a closet floor” was present, which implied that the slipper had to be retrieved from a storage cupboard. In Hong Kong, however, this is not a common practice because slippers are often placed in an open space rather than confined to a cupboard at home. In addition, the inclusion of such details would also add complexity and detract attention from the main purpose as described earlier. Hence, the phrase “…from the front of the closet floor” was removed. In items 8 and 9, “car” was adopted within these questions as the type of vehicle or transportation for determining balance confidence associated with their access. “Car,” however, is not a common mode of transportation among elderly people in Hong Kong because they tend to use a variety of public transports such as a bus, minibus, or taxi. It was, therefore, considered more appropriate to replace the word “car” with a broadly worded term “transportation” to allow for personal interpretations of the relevant mode by the respondents themselves. Finally, for item 16 concerned with perceived balance confidence in negotiating wet and slippery outdoor surfaces, the original wordings “icy sidewalks” were removed because the conditions do not apply in Hong Kong’s climate. These wordings were instead replaced with “wet and slippery pavement.” The 4 modified questions are summarized in table 2 (right-hand column). Following Chinese translations performed on all items (the 4 modified and unchanged original items) of the ABC scale, they were all found to show conceptual, semantic, and technical equivalence. The Chinese translated items (appendix 1) were also found to be understood by the 3 older adults in the pilot test that were subsequently adopted in the next phase for validation testing. Slight modifications to the original testing instructions of the ABC scale were necessary with elderly respondents who were less educated to improve clarity.

Table 2. Results of 4 Modified Activities of the ABC Scale

Original Items of the ABC Scale	Cultural Relevance of Items					Modified Items of the ABC-C Scale
	Interjudge Agreement per Rating (%)
	1	2	3	4	5
3.Bend over and pick up a slipper from the front of a closet floor	0	40	10	50	0	Bend over and pick up a slipper from the floor
8.Walk outside the house to a car parked in the driveway	0	20	30	50	0	Get into or out of a transportation you mostly use
9.Get into or out of a car	10	70	10	10	0	Walk out of the house to get to one form of transportation
16.Walk outside on icy sidewalks	80	0	20	0	0	Walk outside on wet and slippery pavement

NOTE. The rating values are as follows: 1 (very irrelevant), 2 (irrelevant), 3 (uncertain), 4 (relevant), and 5 (very relevant).

Reliability of the ABC-C Scale 

The items of the ABC-C scale showed high internal consistency with a Cronbach α coefficient of .97 (table 3). Further evidence contributing to such a favorable result consisted of moderately strong item-total correlations found for all 16 items that ranged from .71 to .88.²⁵ The α value of .97 was further analyzed to determine if deletions of each item would have significant impact on this value. The result revealed a lack of such evidence supporting the retention of all 16 items of the instrument.

Table 3. Internal Consistency of the ABC-C Scale

NOTE. Cronbach α coefficient of ABC-C scale equal to .97.

Excellent test-retest reliability of the ABC-C scale was found as reflected in an ICC of .99 (95% confidence interval [CI], .99−1.0) shown in table 4. The high ICC value (>.75) indicated excellent stability and repeatability of the scale items across a 2-week interval.²⁵ Nunnally and Bernstein²⁶ further suggested that an ICC of about .95 should be considered as desirable if measures were to be used to monitor changes of individuals over time. For each item, the ICC value ranged from .73 to .98, with the highest as item 5 (stand on your tip toes and reach for something above your head) and the lowest as item 11 (walk up or down a ramp). A high ICC value of .85 (95% CI, .72−.93) for interrater reliability of the scale was also revealed (see table 4).²⁵, ²⁶ This finding indicated very good agreement and high reproducibility of the instrument in assessments conducted by more than 1 rater. The ICC value of each activity ranged from .45 to .89, with the highest for item 15 (step onto or off an escalator while holding onto parcels such that you cannot hold onto the railing) and the lowest for activity item 10 (walk across a parking lot to the mall).

Table 4. Test-Retest Reliability, Interrater Reliability, and Factor Analysis of ABC-C Scale

NOTE. For factor analysis, the eigenvalue equals 11.15 and the cumulative percentage of variance explained is 69.6.

Abbreviation: NA, not applicable.

Validity of the ABC-C Scale 

Factor analysis was performed by using a principal components analysis, followed by a varimax rotation. All the items were found to intercorrelate at greater than the recommended strength of 0.3, which confirmed the suitability of the data for factor analysis. Other assumptions were also met which included the generation of a Kaser-Meyer-Oklin value (.92) greater than the minimum recommended value of .60,²⁷ and the Barlett’s test of sphericity also reached statistical significance at P less than .05.²⁸

The principal components analysis revealed the emergence of 1 factor with an eigenvalue exceeding 1 (see table 4). All 16 items displayed high loadings, which ranged from .75 to .90 with 69.66% of total variance explained. These findings reflect a coherent 1-factor structure.

Self-Perceived Balance Confidence of Older Adults in Hong Kong 

The mean perceived balance confidence level ± standard deviation (SD) of community-dwelling older adults in Hong Kong as measured by the ABC-C scale was 71.6±23.7, with scores ranging from 48.4 to 89.9. The highest level of confidence was found for balance associated with “stepping on or off an escalator while holding onto parcels such that you cannot hold onto the railing” (item 1), and the lowest was for “walking around the house” (item 15).

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Discussion 

In the present study, the original version of the ABC scale was translated into Chinese (ABC-C scale), and its psychometric properties were examined. The translations involved a rigorous process that examined the equivalence of scale contents and also the use of an expert panel. The use of expert opinion is a conventional method used for development or validation of instruments because it is regarded as a simple, direct, and useful means for gathering content-related information about a concept.²⁹ The selection of this approach in the present study has enabled contents of the original ABC scale to undergo an extensive review and modifications were necessary, to ensure they were culturally appropriate for use within a Chinese community. Four items were modified, which predominantly involved changes in their wordings to becoming more generally phrased to accommodate for sociocultural differences identified between Hong Kong and Canada, where the original scale was developed. Forward and backward translations were also adopted in the study that contributed to rigor because such methods are acknowledged in the literature as one of the most adequate translation processes because it involves a number of independent reviews.³⁰

The validation results also found the ABC-C scale to display very good to excellent reliability and validity. High internal consistency (α=.97) (see table 3) was shown, which concurred with those of the original English ABC scale who reported α values of .96²¹ and .98.²³ In addition, the fact that the 4 modified items of the scale did not result in reduced internal homogeneity of the instrument lend support to the high-quality translations performed in the present study. The ABC-C scale also showed excellent test-retest reliability with an ICC value of .99 (see table 4), which was also slightly higher than the .92²¹ and .89²³ that were reported for the original scale. This study expands on the construct validity and interrater reliability of the original ABC described. The present study was the first to contribute new research evidence on these aspects. Results of a factor analysis conducted on the ABC-C scale showed a coherent 1-domain structure that supports the construct investigated (self-perceived balance confidence). An ICC value of .85 was also found that indicated very good interrater reliability of the instrument. Such positive findings could be explained by the face-to-face interview method adopted and clearer modified instructions achieved for administering the scale. This interview method was found effective with older adults, particularly with those who had low educational levels, because it allowed them the opportunity to clarify queries they had about the testing contents and procedure. There were, however, 2 items (items 4, 10) that showed lower levels of interrater reliability, with moderate ICC values of .54 and .45, respectively. For item 4 (reach for a small can off a shelf at eye level), this could have been because of differences in the modes of instruction delivered about the item between each interviewer, which resulted in discrepant assessment findings. With regard to this item, some respondents had required only verbal explanations, whereas others required additional demonstrations of the action involved of the mentioned activity. As for item 10 (walk across a parking lot to the mall), the level of difficulty associated with performing such activity could have been opened to multiple interpretations by different respondents because this could vary in accordance with perceptions of different geographic locations in Hong Kong. These 2 items would benefit from further review in future studies.

A mean level of self-perceived balance confidence of 71.6 (table 5) was identified with the 100 elderly participants in the study. This was higher than the ABC score (59.6) reported in an earlier study²¹ conducted on 60 older Canadian adults. Such difference might be explained by the higher mobility functions of respondents in the present study because 63% to 83% were able to walk indoors and outdoors without aids, with 86% able to maintain regular exercise. Because the Hong Kong sample were relatively well community-dwelling elderly people, it will be useful to replicate this study on those who are older or more frail in future investigations to enhance generalization of our current findings to the broader elderly population. It is interesting to note that for the modified item 16 (walk outside on wet and slippery ground), the score of 57.2 derived in the present study was much higher than that found (20.7) in an earlier study²¹ for the same item from the original ABC scale (walk outside on icy sidewalk). The differences might be explained by differences in perceived levels of difficulty associated with maintaining balance in these 2 activities. Specifically, “walk outside on icy sidewalk” in the original version would appear to require a higher level of balance function than walking on “wet and slippery” surface in the present Chinese-translated scale. The results of a study conducted with 475 participants³¹ showed that an ABC score of 67 or below could predict future fall. Because the Hong Kong population in the present study had an ABC-C score higher than this cutoff score, this may suggest that older adults in Hong Kong are less prone to having a fall. Further study is necessary to verify this and determine the cutoff score for fall prediction in Chinese older adults by using the ABC-C scale.

Table 5. Comparison of ABC-C Score (present study) and the Original English-Version ABC Score²¹

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Conclusions 

The contents of the ABC-C showed good conceptual and cultural relevancy for measuring self-perceived balance confidence in Chinese older adults who are living in Hong Kong. This is supported by found evidence of good validity and reliability of the instrument. It will be useful as a screening tool in clinical and research work for advising appropriate fall preventions and other useful interventions. Future research can address the sensitivity, predictive, and discriminative validity of the ABC-C scale. Results of the current study will also provide useful grounding for future validation work and intended use of this tool with Chinese older adults who are living in other countries or cultures.

Supplier

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Acknowledgment 

We thank Peggo Lam for the statistical advice.

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APPENDIX 1. Chinese Version of Activities-Specific Balance Confidence Scale 

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References 

1. Ho SC, Woo J, Chan SS, Yuen YK, Sham A. Risk factors for falls in the Chinese elderly population. J Gerontol A Biol Sci Med Sci. 1996;51:M195–M198
   • View In Article
   • MEDLINE
2. American Geriatric SocietyBritish Geriatric SocietyAmerican Academy of Orthopedic Surgeons. Guidelines for the prevention of falls in older person. J Am Geriatr Soc. 2001;49:664–672
   • View In Article
   • MEDLINE
   • CrossRef
3. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319:1701–1707
   • View In Article
   • MEDLINE
   • CrossRef
4. Cumming RG, Salkeld G, Thomas M, Szonyi G. Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission. J Gerontol A Biol Sci Med Sci. 2000;55:M299–M305
   • View In Article
   • MEDLINE
   • CrossRef
5. Tinetti ME, Williams CS. The effect of falls and fall injuries on functioning in community-dwelling older persons. J Gerontol A Biol Sci Med Sci. 1998;53:M112–M119
   • View In Article
   • MEDLINE
6. Aoyagi K, Ross PD, Davis JW, Wasnich RD, Hayashi T, Takemoto T. Falls among community-dwelling elderly in Japan. J Bone Miner Res. 1998;13:1468–1474
   • View In Article
   • MEDLINE
   • CrossRef
7. Howland J, Peterson EW, Levin WC, Fried L, Pordon D, Bak S. Fear of falling among the community-dwelling elderly. J Aging Health. 1993;5:229–243
   • View In Article
   • MEDLINE
   • CrossRef
8. Legters K. Fear of falling. Phys Ther. 2002;82:264–272
   • View In Article
   • MEDLINE
9. Friedman SM, Munoz B, West SK, Rubin GS, Fried LP. Falls and fear of falling: which comes first? (A longitudinal prediction model suggests strategies for primary and secondary prevention). J Am Geriatr Soc. 2002;50:1329–1335
   • View In Article
   • MEDLINE
   • CrossRef
10. Howland J, Lachman ME, Peterson EW, Cote J, Kasten L, Jette A. Covariates of fear of falling and associated activity curtailment. Gerontologist. 1998;38:549–555
    • View In Article
    • MEDLINE
    • CrossRef
11. Maki BE, Holliday PJ, Topper AK. Fear of falling and postural performance in the elderly. J Gerontol. 1991;46:M123–M131
    • View In Article
    • MEDLINE
12. Arfken CL, Lach HW, Birge SJ, Miller JP. The prevalence and correlates of fear of falling in elderly persons living in community. Am J Public Health. 1994;84:565–570
    • View In Article
    • MEDLINE
    • CrossRef
13. Yardley L, Smith H. A prospective study of the relationship between feared consequences of falling and avoidance of activity in community-living older people. Gerontologist. 2002;42:17–23
    • View In Article
    • MEDLINE
    • CrossRef
14. Lachman ME, Howland J, Tennstedt S, Jette A, Assmann S, Peterson EW. Fear of falling and activity restriction: The Survey of Activities and Fear of Falling in the Elderly (SAFE). J Gerontol B Psychol Sci Soc Sci. 1998;53:43–50
    • View In Article
15. Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs: Prentice-Hall; 1986;
    • View In Article
16. Hatch J, Gill-Body KM, Portney LG. Determinants of balance confident in community-dwelling elderly people. Phys Ther. 2003;83:1072–1079
    • View In Article
    • MEDLINE
17. Li F, McAuley E, Fisher KJ, Harmer P, Chaumeton N, Wilson NL. Self efficacy as a mediator between fear of falling and functional ability in the elderly. J Aging Health. 2002;14:452–466
    • View In Article
    • MEDLINE
    • CrossRef
18. Tinetti ME, Powell L. Fear of falling and low self-efficacy: a cause of dependence in elderly persons. J Gerontol. 1993;48 Spec No:35–38
    • View In Article
    • MEDLINE
19. Tinetti ME, Mendes de Leon CF, Doucette JT, Baker DI. Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. J Gerontol. 1994;49:M140–M147
    • View In Article
    • MEDLINE
20. Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling. J Gerontol. 1990;45P:239–243
    • View In Article
21. Powell LE, Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci. 1995;50:M28–M34
    • View In Article
22. McAuley E, Mihalko SL, Rosengren K. Self-efficacy and balance correlates of fear of falling in the elderly. J Aging Phys Act. 1997;5:329–340
    • View In Article
23. Parry SW, Steen N, Galloway SR, Kenny RA, Bond J. Falls and confidence related quality of life outcome measures in an older British cohort. Postgrad Med J. 2001;77:103–108
    • View In Article
    • MEDLINE
    • CrossRef
24. Sartorius N, Kuyken W. Translation of health status instruments. In:  Orley J,  Kuyken W editor. Quality of life assessment: international perspectives. Heidelberg: Springer-Verlag; 1994;p. 4–18
    • View In Article
25. Portney LG, Watkins MP. Foundations of clinical research: applications to practice. 2nd ed.. Norwalk: Appleton & Lange; 2000;
    • View In Article
26. Nunnally JC, Bernstein IH. Psychometric theory. 3rd ed.. New York: McGraw-Hill; 1994;ch 7
    • View In Article
27. Tabachnick BG, Fidell LS. In: Using multivariate statistics. 3rd ed.. New York: HarperCollins; 1996;ch 13
    • View In Article
28. Barrlett MS. A note on the multiplying factors for various chi square approximations. J R Stat Soc B. 1954;16:296–298
    • View In Article
29. Haynes SN, Richard DC, Kubany ES. Content validity in psychological assessment: a functional approach to concepts and methods. Psychol Assess. 1995;7:238–247
    • View In Article
    • CrossRef
30. Maria G, Maria BV. Research with Hispanic populations. In: Applied Social Research Series. Vol 23:Newbury Park: Sage; 1991;
    • View In Article
31. Myers AM, Fletcher PC, Myers AH, Sherk W. Discriminative and evaluative properties of the Activities-specific Balance Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci. 1998;53:M287–M294
    • View In Article

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