The Chinese version of the Citizenship Measure (CM): Internal consistency and test-retest reliability among Chinese adults in mental recovery

Wong, F.Y., Wong, K.K.L., Lam, P.C.W., Chin, L.Y., Fung, T.C.T., Rowe, M. The Chinese version of the Citizenship Measures: Internal consistency and test-retest reliability among Chinese adults in mental recovery. American Journal of Psychiatric Rehabilitation. (accepted for publication on 14 April 2024)

Introduction

Citizenship is defined as a person's strong connection to the 5 R's of the rights, responsibilities, roles, resources, and relationships that society offers its members, and a sense of belonging in society through public and social institutions and associational life (Rowe, 1999). By adopting the recovery model and the recovering citizenship approach in our services, the care provided to people in recovery can be more comprehensive, diverse, and effective to meet variations of the mental health needs of individuals.

The Richmond Fellowship of Hong Kong started adopting the citizenship concept to its community mental health services and carried out the Citizens Project in 2020. A validated Chinese version of Citizenship Measure (CM (Chinese)) was needed to assess the strength of people's connection to the 5 R's and the strength and vulnerability of our citizenship work.

Research period: March – July 2019

Objectives

• To develop the CM (Chinese).
• To evaluate the reliability of the CM (Chinese) by testing its internal consistency and test-retest reliability with a sample of people in recovery who were receiving community mental health services.

Methods

Translation

• The original English version of the CM (Rowe et al., 2012) was translated into Chinese and then back-translated into English. 
• The accuracy of the translation was enhanced by the developer of the original English version.
• Eight service users and two staff members pre-tested the Chinese version followed by a cognitive interview to provide insight into their perception of the question items.
• Any question item or word that was found unacceptable, offensive, or difficult to understand was revised.

Pilot-testing of the final version

• Same as the original English version, the CM (Chinese) consisted of 46 items. Items were categorized in seven clusters: personal responsibilities, government and infrastructure, caring for self and others, civil rights, legal rights, choices, and world stewardship.
• People in recovery aged 18 or above receiving mental health services from RFHK and could communicate in Chinese, were invited to participate in the pilot-testing of the CM (Chinese). 
• The CM (Chinese) was completed twice with the second administration 4 weeks after the first one.

Results

• A total of 212 service users completed the CM (Chinese). A sub-group with 101 participants completed the same CM (Chinese) four weeks after the first assessment.
• CM (Chinese) showed an excellent internal consistency with an overall Cronbach’s Alpha of 0.96. Alpha ranged from 0.61 to 0.88 in the seven clusters. (Table 1)
• CM (Chinese) had a good test-retest reliability with an overall intraclass coefficient (ICC) of 0.83. ICC ranged from 0.71 to 0.84 in the seven clusters. (Table 1)

Table 1. Internal consistency and test-retest reliability of CM (Chinese) 

^#Internal Consistency: The degree of interrelationship or homogeneity among the items on a test, such that they are consistent with one another and measuring the same thing.

^†Test-retest Reliability: The agreement of the clusters and the total mean scores between the first and second assessments

• The overall citizenship mean score of the 212 service users was 3.38±0.64 (Highest possible mean score = 5). The respondents had the highest mean score on “Choices” (3.54±0.70), and the lowest mean score on “World stewardship” (3.14±0.78). 
• Only age was found significantly correlated with the cluster score of "Caring for self and others" (r = 0.15, p=0.027). The score of “Caring for self and others” increased as the age increased. 

Conclusion

This study confirms the internal consistency and test-retest reliability of the CM (Chinese) in people in recovery in Hong Kong. The tool can be used in assessing the seven clusters and for comparing citizenship scores before and after an intervention, thus facilitating targeting service needs of individuals and identifying areas for service development and improvement. 

The overall citizenship mean score revealed that the service users only “sometimes” perceived themselves as citizens in the community or involved in citizenship-related activities. The extent of experiencing the 5 Rs was average. 

References

Rowe, M. (1999). Crossing the border: Encounters between homeless people and outreach workers. University of California Press, Berkeley.

Rowe, M., Clayton, A., Benedict, P., Bellamy, C., Antunes, K., Miller, R., Pelletier, J.-F., Stern, E., & O’Connell, M.J. (2012). Going to the source: Creating a citizenship outcome measure by community-based participatory research methods. Psychiatric Services, 63(5), 445-450.