The Construct Validity of the CES-D among HIV-Infected Perinatal Thai Women : Explanatory and Confirmatory Factor Analysis

It is important to measure depressive symptoms in HIV-infected individuals because depressive symptoms have been found to be correlated with faster progression to AIDS. Worldwide, the CES-D has been used to assess depressive symptoms and examined for its construct validity. However, no previous studies have investigated the CES-D’s construct validity among HIV-infected perinatal women. Therefore, the objective of this study was to examine the construct validity of the CES-D using both explanatory and confirmatory factor analysis among HIV-positive perinatal women in Thailand. Results showed that, overall, the CES-D is a 4-factor instrument with good construct validity and can be used to evaluate depressive symptoms among HIV-positive perinatal Thai women. However, some items from our study loaded differently on the 4 factors from Radloff’s model. Finally, the CES-D can be used as a general-factor scale without being compromised. DOI : 10.14302/issn.2324-7339.jcrhap-12-158


Introduction
HIV/AIDS is one of the most significant health problems worldwide, with serious impact on mortality, morbidity, the use of health care services, and the overall quality of life among those infected and the families and communities surrounding them. 1 Affecting over 33 million people worldwide, including at least 600,000 Thai adults (ages 15-49), the epidemiology of HIV is changing globally. 2Overall, women of childbearing age are the fastest-growing group of individuals to be infected with HIV.In Thailand, over 21,000 pregnant women are infected. 2Generally, HIV infections cause greater problems for people in developing countries such as Thailand than for those in developed countries, partly because of a lack of antiretroviral medications.Studies have shown that depressive symptoms are associated with greater nonadherence to antiretroviral treatment, 3 faster disease progression, 4,5 and poorer quality of life. 6ternal depression is a significant cause of morbidity among child bearing women in resource-poor countries. 7,8Thus, early detection of depression in the perinatal period is important.However, few studies of depressive symptoms in HIV-positive individuals have focused on pregnant and postpartum women, although the perinatal period is a time in which women are particularly vulnerable to depressive symptoms, partly due to hormonal changes. 9,10Previous depressive symptoms, 11 perceived stress, social isolation, disengagement coping, 12 and drug use, 13 have been found to be psychosocial and behavioral predictors of perinatal depressive symptoms as well.Studies that have examined depressive symptoms using the Center for Epidemiologic Studies for Depression scale (CES-D) 14 in HIV positive pregnant women in Thailand have demonstrated excellent internal consistency of the tool. 15 -18 Te construct validity of the tool in this target population , however, has not yet been examined in detail.
0][21][22][23][24][25][26][27][28][29][30][31][32][33] Van Lieshout, Cleverley, Jenkins, and Georgiades compared postpartum immigrant and non-immigrant women using confirmatory factor analysis to determine that both groups conceptualize depressive symptoms in similar ways. 31Canaday, Stommel, and Holzman found an almost identical factor model across white and African American pregnant women. 27Conversely, studies that examined the construct validity of the CES-D using exploratory factor analysis (EFA) showed various results, ranging from 1-factor to 4-factor structure.To our knowledge, only two studies in Thailand have examined the construct validity of the CES-D: one in college students 34 and the other in communitydwelling elders. 25The study among college students using EFA supported the 4-factor structure of the CES-D 34 although some items loaded on different factors as proposed by Radloff.The study among elderly Thais (Continued on page 37) using CFA, however, revealed that the CES-D could be used either as a general-factor or as a 4-factor structure. 25The objective of this study was thus to examine the construct validity of the CES-D Thai version among HIV-infected perinatal women in Thailand using both EFA and CFA.

Participants
We collected two data sets-one of pregnant (n=127) and the other of postpartum (n= 85) HIVinfected women-between 2004 and 2007 in eastern Thailand.The original correlational studies for which the data sets were collected examined factors predicting depressive symptoms among perinatal Thai women 15,16 Five internal review boards in Thailand and the USA approved the correlational study protocols.Eligible participants were Thai women who were at least 18 years old, able to read and write in Thai, and diagnosed with an HIV infection.Demographic characteristics of the participants in both data sets were found to be nonstatistically different in terms of age, education, income, and marital status using Chi-square or independent ttest.In total, ninety percent were married or living with a partner, sixty one percent had sufficient family income, fifty four percent were employed, and forty five percent had schooling through junior high. 14Data in both groups were also collected at the same four hospitals.Thus, we deemed it logical to combine the two data sets for the present study because the women from both groups were similar in terms of their socioeconomic status and geographical location.Participants filled in questionnaires in a private hospital room after an informed consent was signed.Data collectors checked the completeness of all of the respondents' questionnaires on the spot.If some parts were found incomplete, they asked the respondents to complete the parts they inadvertently left out.This practice helped our data collection to be nearly perfect with an overall missing values for all measures at <.001%.No identifiable information is used in our results.

Materials
The original studies used the 20-item CES-D 14  "rarely or none of the time" (0) to "most or all of the time" (3).Possible total scores range from 0 to 60 with higher scores indicating more depressive symptoms.The CES-D is considered a screening tool and not a diagnostic tool for depression. 14The Cronbach's alpha for this combined data set was .90-thefirst clue that the CES-D had good validity in our study. 35e measures of self-esteem and emotional support (Thai version with back translation) used in the original studies are also described below.Correlations between the CES-D and these related conceptual measures were performed and will be presented in the results and discussion.The 10-item Rosenberg Self-Esteem scale 36 was used to measure self-esteem with a 4-point Likert scale ranging from strongly disagree (1) to strongly agree (4).Possible scores range from 10 to 40 with higher scores indicating higher self-esteem.The Cronbach's alpha for this combined data set was .78.
Emotional support was measured by the Multidimensional Scale of Perceived Social Support (MSPSS) 37,38 with a 7-point Likert scale ranging from strongly disagree (1) to strongly agree (7).Possible scores range from 12 to 84 with higher scores indicating more emotional support.The Cronbach's alpha for this combined data set was .87.

Factorability of the data
In factor analysis, the magnitude of sample size considered factorable is controversial.While Sapnas and Zeller found that a sample size as small as 25-50 subjects was adequate in their study, others recommended a larger sample size of 100 through over 1,000 35,[39][40][41][42][43][44] Some scholars recommend that the sample to variable/indicator ratio be used to ensure adequate sample size with the suggested ratio ranging from 3:1 to 20:1 35,[42][43][44][45][46] However, there is evidence that the sample size is not the sole indicator of factorability.With high correlations among indicators, a small sample size is adequate for factor analysis. 43,47,48In factor analysis, correlations among indicators of at least .30should be present. 35,39If no correlation is greater than .30,factor analysis should not be performed. 35,45r  35,39 Although it is suggested that the sensitive -to-sample-size Bartlett's Test of Sphericity be tested only when the sample to indicator ratio is < 5:1, we wanted to check its value in our sample and found that the test was significant (Chi-square = 1,675.7,df =190, p <.001), thus favoring factorability. 35,39Because there is no universal consensus on the best criterion to determine the number of factors in EFA, we applied 5 criteria to guide our decision-making: eigenvalues, Scree test, percentage of explained variance for each factor, cumulative percentage of explained variance, and rotated factor loadings.Table 1 shows that 4 factors are recommended, using the eigenvalue cutoff of > 1, 49 while the Scree test/plot 50 suggests 3 factors (an analogy is that, when you flex your elbow, the number of factors is shown starting at the elbow plus those along the forearm; see highlighted line in Figure 1).should be retained, as it is recommended that a factor with at least 5% of such a variance be kept. 35,39With a recommendation for social and health science research, 35,44,51 a cumulative percentage of explained variance of at least 50% is adequate in EFA.Thus, a 4factor structure was determined.
Finally, we examined our rotated factor loadings generated from varimax rotation with suppression of any loading <.40 for a clear presentation.Table 2 shows  substantially significant (Figure 2).No multicollinearity was found as none of the correlation was higher than .90 43,52tandardized factor loadings ranged substantially from .46 to .82.Correlations among factors were moderate to strong and appropriate, ranging from .44 to .82(Figure 2).The average explained      35 Results of factor variances ranged from 26.50% to 46.03% (Figure 2).Ideally, the value of at least .50 is desirable. 35Nevertheless, our explained factor variances were significantly higher than those of the previous Thai elderly whose variances ranged from 10.1%-43.8% . 22xt, we examined the standardized residuals (results not shown) which function similar to Z scores with fitted residuals divided by their respective standard error. 35The value usually starts at 0, which indicates a perfect fit of the model. 40A standardized residual of over 2.58 indicates a model misfit for particular variances/ covariances. 40,53There is no percent cutoff of misfit residual values. 43 3).Even though NFI is smaller than .90, it is suggested that CFI be used over NFI as CFI is adjusted for by taking the sample size into account. 54If the most recent recommendation of >.95 is used, 55 then IFI and CFI values indicate somewhat model fit.However, we have reasons to believe that our data fit the model well.First, our results are substantial and meaningful as evidenced by moderate-to-strong magnitudes of factor loadings and also moderate-tostrong correlations among factors.Second, our CFA was performed using a small sample size, so it is reasonable to use the cutoff of .90instead of .95 to justify model fit. 36,48CFA usually requires a larger sample size than EFA, which is true in our case.The sample to variable ratio is slightly over 10:1 for EFA but appears to be much smaller for CFA in our study.Based on Figure 3, the number of parameters to be estimated is 69: 16 regression coefficients, 9 covariances, 24 factor and indicator variances, and 20 error term variances.Thus, the sample to indicator ratio is 212/69 = 3:1, which is small.

Because the previous study among elders in
Thailand reported that a general factor of the CES-D also fit as well as the 4-factor structure using CFA, 25 we next tested a general factor of the CES-D in our HIV population using second-order CFA, based on the revised model.The second-order general factor was scaled to one so that all paths from it to each first-order factor could be calculated. 43The general factor is measured indirectly through the 4 first-order factors.Therefore, it is evident that the 4-factor CES-D model based on Radloff's recommendation does not fit our data well. 56 sum, both our EFA and CFA results supported Radloff's in that the CES-D comprises 4 factors.21][22][23][24][25][26][27][28][29][30][31][32][33]57  Also, our study showed that a general factor of the CES-D fit the data as well as our 4-factor model.
This result is consistent with the previous study among elders in Thailand. 25Therefore, the CES-D could be used as a general factor or as a 4-factor scale among HIVpositive perinatal women in Thailand.

Correlations between the CES-D and MSPSS/RS-E
To further investigate the construct validity of the CES-D, we ran Pearson's correlations between the CES-D and MSPSS (emotional support) and the CES-D and RS-E (self-esteem).Results showed that both relationships were statistically negative with Pearson's r at -.248 and -.519, respectively.These results indicate divergent validity between the CES-D and emotional support because its absolute r is less than .50, 35while there is convergent validity between the CES-D and selfesteem since the absolute r value is greater than .50. 35 These results further suggest that the CES-D has good construct validity as it is appropriately inversely correlated with the positive concepts of emotional support and self-esteem. 58

Conclusions
In general, it seems that the CES-D's overall construct validity is relatively stable across cultures and subjects.Results from our study show that the CES-D is a valid measure with good construct validity which can be used either as a general factor or as a 4-factor instrument among HIV-infected perinatal women in Thailand.Some items in the CES-D from our study loaded differently from Radloff's study.Therefore, when subscales are used in the target population, different loadings of items between Radloff's and our study should be observed.
There is support in the literature for combining both EFA and CFA. 30Our study found such a combination to be effective.Based on our study, it is logical and helpful to perform EFA first, followed by CFA.

Both
EFA and CFA were performed to examine the construct validity of the CES-D.EFA was performed first because the factor structure of the scale has not been studied among HIV-positive perinatal women before, while CFA was performed by AMOS version 21 to test EFA results by verifying model fit.In EFA, the principal component analysis (PCA)-the most widely used data reduction technique-was used to extract factors using SPSS version 20.Varimax rotation followed to maximize the difference between low and high factor loadings for clear interpretations among factors. 39In CFA, the maximum likelihood estimation is used.A hypothesized graphical 4-factor structure of the CES-D based on the EFA results was drawn and run using AMOS Graphics.To examine if the model fits the data well, factor loadings, correlations among factors, standardized residuals, and several model fit indices were scrutinized.Finally, we further examined the construct validity of the CES-D in relation to 2 related constructs: emotional support and self-esteem.Pearson's Product Moment Correlation was performed to examine the relationship between the CES-D scores and the MSPSS scores and between the CES-D scores and the RS-E scores.

4 factors
along with their respective items.However, 3 items (Depressed, Good, & Failure) had cross loadings and did not load cleanly because the difference between the loadings on the 2 factors is <.20.35,39We placed Depressed in Factor 1 and Good in Factor 2 because they make sense theoretically.We placed Failure in Factor 1 (Depressed Affect) rather than Factor 2 (Positive Affect) because Failure loaded substantially on both factors, and the loading difference is trivial (.512-.447= .065).Importantly, Failure is a negative concept, so it theoretically belongs better to Depressed Affect than Positive Affect.See Table3 fora comparison of four factor item loading based on Radloff's, Vorapongsathorn et al., and the current study's findings.At this point, we decided that a 4-factor structure is the best model for our data.CFA was performed next.CFA With CFA, we used EFA results to create a 4factor structure of the CES-D using AMOS Graphics and hypothesized that: 1) the CES-D is a 4-factor model; 2) correlations among factors substantially exist; and 3) all factor loadings onto their respective factors are substantially present.Results showed that all of the relationships among factors and those between indicators and factors (factor loadings) were

Figure 1 :
Figure 1: Scree Test Figure 2: Hypothesized model: 4-Factor model based on EFA results Factor % Variance explained by its respective items Depressed Affect 46.03 Somatic Complaints 26.50 Positive Affect 36.64 Interpersonal Relationship 39.08 Subsequently, we examined model fit indices using Chi-Square, Normed Fit Index (NFI), Incremental Fit Index (IFI), Comparative Fit Index (CFI), Root Mean Squared Error of Approximation (RMSEA) along with its confidence interval, and PCLOSE.These results are shown in Figure2.Given that the Chi-square value is extremely sensitive to the sample size, we did not use Chi-square to judge model fit.Using a former recommended value of >.90 as a good fit cutoff,40 NFI, IFI and CFI values indicated poor fit.The RMSEA (<.80) and its CI short range are promising, indicating that the sample errors' prediction is precise.However, the closeness of fit (PCLOSE) was significant (p <.05), indicating that there was too large of a sampling error,40 thus demonstrating poor fit.To search for clues to improve model fit, we investigated modification indices (MI's) and found that the largest value was a covariate of the error terms for Cry and Sad, indicating that these two indicators share something in common and may measure a similar trait. 40,43This makes sense because Cry and Sad seem very close theoretically.The MI was 32.02 with an estimated parameter change (Par Change) of .147.A model restructuring was thus warranted because of this theoretical and empirical evidence. 40Therefore, we added a covariate between the error terms of Cry and Sad and reran the analysis.Factor covariate and factor loading results were significant and substantial (results not shown).Model fit results showed that all other values were acceptable except for PCLOSE with its value of .036,suggesting that we should look into MIs for possible respecification of the model.The largest MI (16.35 with Par Change of .145)was found between the error terms for Failure and Fearful, so we correlated them and reran the analysis.This time, all model fit indices and PCLOSE taken together ensured model fit (Figure 3).The Chi square difference test, comparing the present model with the hypothesized model, also showed a significant result.This test is done by subtracting the revised model's Chi square from the hypothesized model's Chi square (331.63-280.19= 51.44 = the Chi square difference value/Chi square change).The degree of freedom is performed similarly to the Chi square values, and in our study yielded a value of 2 (164-162).Using the Chi square table, the Chi square difference's p-value was <.001, thus indicating that the present revised model statistically fits the data better than the hypothesized model.Also, results from this respecified model revealed that the factor loadings remained significant and substantial (Figure3).The average explained variances for the factors ranged from 26.50% to 45.31% (Figure3).Based on our visual inspection of the standardized residual matrix, we found only 3 values over 2.58 (2.99, 3.01, & 3.06), which are smaller than

Figure 3
Figure 3: Revised Model: 4-factor model based on EFA results with two covariates

Figure 4
Figure4shows that all indicators loaded substantially onto its respective first-order factor.The average explained variances for the first-order factors ranged from 26.20 % to 45.30% (Figure4).The standardized residual matrix showed 3 values over 2.58 (3.00, 3.01, and 3.06) not too far off from 2.58, and much smaller than the 4.0 cutoff, suggesting good fit.The model fit Even though the CES-D is a well-established instrument and is used around the world, no study had examined the construct validity of the CES-D among HIV-positive perinatal women in Thailand before ours.People in different cultures with different health conditions may experience different clusters of depressive symptoms.EFA helped us explore the structure of the CES-D and extract appropriate factors along with their associated indicators in our target population.Because tests for model fit in EFA are not available, CFA based on EFA results was used to verify model fit using standardized residuals and model fit indices.We recommend that future studies use combined EFA and CFA methods when a new tool is examined or when a new population is studied using a well-established tool.There is a limitation to our study in that our participants were recruited from only one region in Thailand.Therefore, generalizability might be limited to only the eastern Thai region.Future studies should examine the construct validity of the CES-D among HIVpositive perinatal women in other regions of Thailand and in other countries beyond Thailand.

Table 3
Comparison of items loaded on 4 factors based on three studies (number of items in parenthesis)