Article Information

Muhammad SR^*

Chancellor & Professor of Surgery Muhammad Medical College, Ibne sina University, Mirpurkhas, Sindh, Pakistan

^*Corresponding Author: Muhammad SR, Chancellor & Professor of Surgery Muhammad Medical College, Ibne sina University, Mirpurkhas, Sindh, Pakistan.

Received: 13 June 2024; Accepted: 21 June 2024; Published: 03 July 2024

Citation: Muhammad SR. Establishing the Construct Validity and Internal Consistency for Urdu Version of Jefferson Scale of Empathy-S (JSE-S). Journal of Psychaity and Psychaitric Disorders. 8 (2024): 144-149.

Abstract

Keywords

Medical education; Jefferson Scale of Empathy; Urdu Version

Article Details

1. Introduction

Empathy is defined as a cognitive attribute that engages understanding a patient’s suffering and concerns combined with an ability to communicate this understanding and an intention to help” [1]. For optimal patient outcome, strong physician-patient relationship is necessary. If patient outcome is to be rationalized, then empathy is considered as key element. Jefferson Scale of Empathy was developed by Jefferson Medical College (now Sidney Kimmel Medical College) of Thomas Jefferson University Center for Research in Medical Education and Health Care. Jefferson Scale of Empathy [2] (JSE) is the most widely used scale to measure empathy. It is available in three versions namely

Medical students (S-version)

Health Professions (HP-version)

Health Professions students (HPS-version)

JSE has been translated into 56 languages. Original version is available in English which has been validated [3-5], with permission to translate it into local language. However, Asano-Gonnella Center for research in medical education & health care did not endorse any translation and therefore it is prime responsibility of researchers to validate translated version of JSE [6]. The translated versions of Jefferson Scale of Empathy have been used in more than 70 countries. Almost all published studies reported Cronbach’s alpha coefficients in range of 0.70 to 0.80 which indicate good reliability [7]. Yet it is important to establish construct validity and internal consistency of any translated version before it is use with confidence.

Objective:

The objective of this study is to establish the construct validity and internal consistency for Urdu translation of Jefferson Scale of Empathy Student version.

2. Methodology

2.1. Ethical Approval

Prior approval taken from Research and Ethical Review board of Muhammad Medical College vide letter no ERB/113/2019.

2.2. Instrument

Urdu version of Jefferson scale of Empathy student version (JSE-S) is used. The Jefferson Scale of Empathy Student Version (JSE-S) has 20 items each is scored on 7-point Likert scale. Among these 10 items refers “positive” and scored as “Strongly Disagree=1……. Strongly Agree=7”. While other 10 items refer “negative” and scored reversely as Strongly Disagree=7, Strongly Agree=1.

As the aim of this study has been to assess the construct validity and reliability of the Urdu version of JSE-S, the average scoring of each item (with standard deviation) calculated and compared with those of the other studies.

Each year 100 students get admission in Muhammad Medical College, making a total of 500 students across the 5 years. As some students failed in their final examination; JSE-S Urdu version was distributed to 521 students between January 2015 and February 2015.  Appropriate information and instructions given to each student to fill the questionnaire and asked not to hesitate in case feel difficulty to understand any item of the questionnaire form. It was also clearly mentioned that responding survey form is not a test of their academic performance and subsequently will not get any reward in any form. Participants were given choice to submit completed form either anonymously or even if they mention name/seat number, yet the identity of any respondent will not be disclosed/share at any forum.

2.3. Data Analysis

Survey forms with answers of 15 questions or less will be considered incomplete and therefore will not considered for data analysis. However when survey forms show response for 16-19 question, the mean score of responses will be calculated and this mean score will be used for missing items. The adequacy and appropriateness of the data for calculating reliability analysis and construct validity, Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy [8] and the Bartlett's Test of Sphericity [9] will be used.  When data found suitable; the reliability analysis will be calculated using Cronbach's α and construct validity by using principal component analysis (PCA) also known as Factor Analysis.

3. Results

The breakup of 521 students with respect to study year and gender is shown in table no 1. Among 521 students, 405 students returned the form giving response rate of 77.88%. however only three hundreds and eighty-eight students answered all 20 items. The table no 1 shows the response rate with respect to year of study and gender. The overall mean empathy in the study was 107.22 (±12.844)/out of 140. The empathy score with ±SD is shown in table no 3. The total empathy and mean empathy of Hojat’s 3 factors were calculated, they were highest for prospective taking (6.09 ± 0.694), then compassionate care (4.97 ± 0.97), and lowest for Standing in Patient’s shoes (3.63 ±1.51) see table no 4.

3.1. Reliability

The internal consistency reliability of the questionnaire had a Cronbach’s alpha coefficient of 0.684 and a Cronbach’s alpha based on standardized items of 0.704.

3.2. Cronbach's Alpha if item deleted

An analysis was run to see how much alpha is affected if each item is deleted. Results are summarized in table 5. Deletion of items causes minimal change to alpha ranging from .650 (Item 14) to 0.697 (Item 18). From this analysis, it appears that all 20 items designed to measure JSE-S, work well and contribute to the overall reliability of JSE-S Urdu Version. As evident from table no 5 that the deletion of items causes minimal change to alpha ranging from .650 (Item 14) to 0.697 (Item 18). From this analysis, it appears that all 20 items designed to measure JSE-S, work well and contribute to the overall reliability of JSE-S Urdu Version.

3.3. Construct validity

Construct validity refers to the degree to which a test or measure assesses the underlying theoretical construct it is supposed to measure. To analyze that the Urdu version of JSE-S actually measures the empathy in the same way as the original English version; we performed Principal Components Analysis (PCA) (a dimension reduction technique). For current study Kaiser-Meyer-Olkin (KMO) test yielded an index of 0.764, suggesting a support for factor analysis. Bartlett’s test of sphericity is 985.518 and is highly significant (P = 000) (indicating a high probability of significant relationships between the variables).

3.4. Principal Component Analysis (PCA)

Factor analysis is the most powerful statistical procedure for scrutinizing relations between observed and latent variables [10]. Three factors F1, F2, F3 viz “Perspective Taking”, “Compassionate Care” and “Standing in Patient’s Shoes” respectively emerged as shown in table no 6.

Table 1: Year of study and Gender distribution

Table 2: Response Rate with respect to Gender and Year of Study

Table 3: Mean Empathy Score with SD

Table 4: 3 Factor Mean Score with SD

Table 5: Cronbach's Alpha if item deleted

Table 6:  Factor analysis for Perspective Taking”, “Compassionate Care” and “Standing in Patient’s Shoes”

4. Discussion

The results of present study confirm the content, validity, reliability of Urdu version of JSE-S.  Overall response rate for questionnaire was 77.88% which is comparatively less when compared to the study of Asma Mostafa et al who reported it to be 81.69%. Gender wise response rate was higher for female students (88.9%) as compared to male (69.26%);  A finding when which is not much surprising as literature showed that female exhibit not only higher response [12], but also found to be better compliant even with psychiatric disorder [13]; female scientists are more collaborative than their male counterparts [14,15].

The overall Cronbach’s alpha for present study was 0.684.  Although a Cronbach alpha above 0.6 had been termed “acceptable by some authors [16], others [17] prefer a figure exceeding 0.7. The deletion of only item 18 would raise Cronbach’s alpha to 0.7. This shows the reliability of the Urdu version of JSE-S.

The principal component analysis shows a three-factor solution that is somewhat similar to the pattern in other studies [11,18,19]. This also provides support for the construct validity of the Urdu version of JSE-S. It is Although not clear, yet our students have scored higher than the Italian students19 for Perspective taking which reflects cognitive skills including information processing, reasoning, appraisal, and communicating empathy, as well as greater altruistic motivation [20]. Imagining the self and imagining the other in pain activate similar neural mechanisms. Imagining the self and imagining the other in pain activate similar neural mechanisms; therefore enable one’s ability to perceive other’s pain in identical manner [21]. We found, increase ability among our students, to perceive others’ pain. This may be explained by the fact that Pakistan is badly affected, for more than 2 decade, by terrorism. As conditions of terrorism is improving since last 4-5 years it will be interesting to note if this trend continues in subsequent years.

Another striking feature for current study was that students showed lesser ability to address the patient’s psychosocial problems and understanding the patient’s experience, feelings and clues [20] than their Italian counterparts [19]. Currently study showed that Pakistani students find it difficult to address client’s psychosocial problems when compared to published literature [22]. The reason for these differences is not clear but may be due to religious, cultural and economical issues.  Islam discourages communication between men and women. In Pakistani culture too, such interaction is discouraged. Joshua Horden [23] has mentioned that some of the religious and cultural taboos adversely affect communication with the patients. It is also known that the patients from higher social classes communicate more actively and show more affective expressiveness, eliciting more information from their doctor. Patients from lower social classes are often disadvantaged because of the doctor's misperception of their desire and need for information and their ability to take part in the care process [24]. Hence the religion, culture and economical factors may have affected the empathy of our patients.

Finally, the item 18R “Physicians should not allow themselves to be influenced by strong personal bonds between their patients and their family members” has raised some concern. This is the only item where our students have scored very low (2.67 out of 7). This item has scored lowest in many other studies too [11,19]. Besides the fact that it is the only item whose deletion would raise Cronbach’s alpha to 0.7, lowering the overall internal consistency of the entire scale. It is also the only item that has failed to load significantly. The problem may lie in the phrasing/wording of the item. It perhaps suggests that it is asking about a non-professional, intimate relationship. The fact that it has been negatively worded may have added to the complexity of the item.

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