Short form of the Changes in Outlook Questionnaire: Translation and validation of the Chinese version

Severely stressful and traumatic experiences can lead to both acute and chronic negative psychological change (e.g. [1‐4]). However positive changes following adversity have also been recognised in philosophy, literature, and religion [5, 6]. Against this backdrop, there is increasing empirical evidence showing that positive psychological changes can also result from the experience of events such as disasters [7], chronic illness [8], heart attacks [9], bone marrow transplants [10], HIV/AIDS [11], cancer[12], rape and sexual assault [13], military combat [14], bereavement [15], injury [16], recovery from substance addiction [17], and in the parents of children with disabilities [18].

The topic of growth through adversity has become the focus of much empirical [19, 20] and theoretical work [21]. Through a process of struggling with adversity, changes may arise which lead the individual to reach a higher level of functioning than that which existed prior to the event. In the recent psychological literature, the positive changes that are observed following severely stressful events have been variously labelled perceived benefits [22], positive changes [23], posttraumatic growth [24], stress-related growth [25] and thriving [26].

A number of valuable psychological theories of positive changes have been proposed. Janoff-Bulman’s shattered assumptions theory[4] was developed prior to the establishment of this field but has provided the fundamental theoretical architecture for the two main theories of positive change, notably the transformational model[21] and the organismic valuing theory[27]. The transformational model provides a comprehensive theoretical description of posttraumatic growth. Individual characteristics, support and disclosure, and, more centrally, cognitive processing involving those structures threatened or nullified by the traumatic events, play important roles in this approach. Somewhat, by contrast, organismic valuing theory attempts to provide an account of positive changes rooted in humanistic psychology wherein post- traumatic stress is viewed as indicative of normal, natural cognitive processes that have the potential to generate positive change of such experiences. Several psychometric instruments have been developed to assess positive changes in the aftermath of adversity. These include: Changes in Outlook Questionnaire (CiOQ [23]); Posttraumatic Growth Inventory (PTGI [24]); Perceived Benefit Scales (PBS [22]); Stress-Related Growth Scale (SRGS [25]); and the Thriving Scale (TS [26]).

While some research has shown that posttraumatic growth is predictive of subsequent positive functioning, other research has failed to show such an effect. This has led to controversy over whether posttraumatic growth is necessarily beneficial including that of Park [28]. This is possibly due, in part, to measurement problems with current definitions of posttraumatic growth failing to distinguish between real growth and illusory growth. Self-reports of growth do not necessarily tally with other indicators as would be predicted. As such the use of retrospective self-report measures should be limited to those contexts in which other forms of assessment are unavailable [29]. In addition, much of the relevant research has been carried out in Western cultures [30] and it is not clear how such instruments might be applied elsewhere.

Although natural disasters are frequent in China, few studies have been published on growth following adversity in Chinese populations. To date only three studies [31‐33] have reported posttraumatic growth in Chinese samples by using the Posttraumatic Growth Inventory (PTGI) which was developed based on a US sample. One study [31] uses the PTGI in Chinese cancer patients after exploring its factor structure. The other two studies use the PTGI and the IES-R to assess the prevalence and predictors of posttraumatic growth in a Chinese sample traumatised by an earthquake [32, 33]. The present study examines a simplified Chinese version of the short form of Changes in Outlook Questionnaire [34], one of the most widely used self-report scales. The advantage of this measure is that it assesses both positive and negative schematic changes experienced following adversity and therefore offers a more complete picture of change.

The CiOQ [23] measures changes following the experience of severely stressful events [35]. The English language measure is composed of two subscales, an 11-item scale assessing positive changes (e.g. “I value my relationships much more now”), and a 15-item scale assessing negative changes (e.g., “I do not look forward to the future anymore”). The 26 items were originally generated by survivors of a shipping disaster in response to an open-ended question asking whether the disaster had changed their outlook on life in any way, either negatively or positively [36]. From respondents’ descriptions, a list of items purporting to represent positive and negative changes was drawn up. Joseph, Williams & Yule [23] reported satisfactory internal consistency for the positive and negative change scales (.83 and .90 respectively) and that those scales were not correlated (r = −.12). The measure has since been used in studies with a wide variety of participants following its experience of severely stressful situations, trauma and adversity, including people vicariously exposed to the 11 September 2001 terrorist attacks in the USA [37, 38]; trauma therapists [39]; and members of general populations who have experienced adverse and traumatic events[35].

The 26-item CiOQ questionnaire is relatively long for both practitioners and others in need of a rapid means of assessment. Therefore, a short form CiOQ (CiOQ-S [34]), in English language, was developed by choosing the five highest loading items from the positive component and the five highest loading items from the negative component based of two-component structure. High internal consistency was reported for this version. Evidence to support the convergent and discriminant validity of the CiOQ-S was found with other measures of stress and trauma-related change. Compared with the CiOQ, the CiOQ-S enables researchers to gather data when there is only a limited amount of time available. This is very useful in many crisis situations.

The aim of this study is to translate the CiOQ-S into simplified Chinese and examine its factor structure, validity and reliability in Chinese earthquake survivors. It is worthy studying the relationship between positive changes and psychological variables as positive changes are assumed to make a difference in people’s lives by affecting levels of distress, well-being or other areas of mental health. Studies addressing the correlates of growth find that ruminative intrusion, social support, positive coping strategy are consistently associated with posttraumatic growth [19]. Correlations between posttraumatic growth and increased positive mental health, reduced negative mental health and better subjective physical health are found among individuals with cancer or HIV/AIDS [40]. Convergent validity was explored through the associations between the simplified Chinese version of the CiOQ-S (CiOQ-SCS) and measures of posttraumatic stress disorder (PTSD) symptoms, anxiety, depression, general health, coping style and social support.

This study validates the CiOQ-SCS for use by professionals in the field of traumatic stress working with Chinese population. The results confirmed the two-component structure of positive changes and negative changes, and correlations with other personality and social psychological variables showed that the CiOQ-SCS correlates significantly with other variables in predictable ways. Higher scores on the CiON-SCS were found to correlate with higher scores on measures of post-traumatic symptomatology and psychological distress. The results also showed the predictable correlations with anxiety, depression, lower social support, less active coping and greater passive coping. Higher scores on the CiOP-SCS were found to correlate with higher rumination-intrusion, lower depression, higher social support and active coping.

Previous work has shown that the negative schematic changes caused by trauma are related to posttraumatic stress [4]. These findings are supported here. In a study of the 911 terrorism attack in the USA, negative changes measured by the CiOQ were the most powerful predictors of heightened distress and diminished psychological well-being in both the short- and longer-term following the attack [37]. This could link to the view that profound challenges to basic assumptions about the self, others, and the world can be one of the most deleterious effects of traumatic experience [4]. These results also support the notion that positive changes are not simply the opposite of psychological distress but may be acting with such distress both independently, increasing positive growth, and in tandem, helping the person with meaning making after a traumatic event. This hypothesis is further supported by the significant correlation shown between positive changes and rumination-intrusion (IES-R). This finding is consistent with a previous study using the full CiOQ showing that positive changes were associated with the rumination-intrusion items but not the sleep-disturbance items of the IES [35]. Theoretical models of growth following adversity (see earlier [21, 27]), propose that some degree of intrusion is necessary for growth to take place, as intrusions are indicative of cognitive processing which is a normal and necessary part of the adaptation process [61, 63]. The finding that positive changes were not correlated with avoidance and hyperarousal is consistent with the full-CiOQ study [35], and also with a review by Zoellner and Maercker which reported no systematic relationship between posttraumatic growth and PTSD symptoms in most cross-sectional studies [64].

The negative correlation between positive change and depression found in this study is also consistent with previous research (e.g. [61, 65, 66]), and provides further evidence for the adaptive role of positive changes. The finding that no correlation existed between positive changes and anxiety is consistent with the review [19]. The null finding between positive changes and GHQ-28 also support the conclusion that no consistent relationship between positive change and general distress can be found in cross-sectional studies [64]

Although there is a wide range of age (19 to 82) in the sample, no significant difference across age groups was found. The low socioeconomic status and low educational level of the sample may have affected the results. Previous studies reported higher levels of education and income are associated with more adversarial growth [19, 33].

As discussed in the background, there is an urgent need for cross-cultural studies on constructs such as growth following adversity that have been primarily investigated in Western populations. There are only three published studies exploring the posttraumatic growth in Chinese sample (see earlier [31‐33]). The present study used an ethnically diverse sample to validate the Chinese version of the CiOQ-S. The inclusion of both positive and negative indicators of a traumatic experience precludes this study from the limitations of traditional trauma research. The study confirmed the 2-component structure of CiOQ-SCS and its reliability in a Chinese sample.

The results of this study revealed high levels of positive changes among Chinese earthquake survivors of low socioeconomic status. Although our sample was relatively small for such work, we have attempted to use a relevant sample rather than relying on a college student sample (see, e.g., [24, 25]).

The authors acknowledge the limitations of this study. First, the sampling method used does not permit us to know how representative our samples were of the earthquake victim population. The sample contained more women than men, and this uneven sampling is not ideal for a psychometric study. However, this reflected the sampling typically found in research of this area [19] and of the survivor population. Second, the measures were presented verbally. People may like to be more positive when they are spoken to than when they are writing out their responses. However, given the level of literacy among the sample, there was little alternative. Third, although the short Chinese version of the CiOQ has reliable psychometric properties, posttraumatic growth is a theoretical concept that has been established within a Western cultural framework. Although at an abstract level the concept of posttraumatic growth appears cross-culturally valid, the operationalisation of the concept may serve to impose assumptions of a Western individualistic society [30] which emphasizes the individuation, uniqueness, and internal attributes of people. Chinese people are more relational and interdependent and emphasize the social context in comparison to their Western counterparts [67]. It is logical to expect that such differences should be relevant to the phenomenon of posttraumatic growth. Further research is needed to explore the nature of posttraumatic growth in Chinese or Eastern population.

There are several implications for future practice. First, this study is cross-sectional, and little is known on how positive changes at one point in time predict health-related outcomes at a later point. There is some evidence to suggest that positive changes predict distress and well-being in longitudinal studies [68, 69]. CiOQ-S could be used in longitudinal studies assessing the relation between positive and negative changes and subsequent indices of psychological and physical functioning. Second, since positive changes are not simply the opposite psychological distress, investigations into therapeutic techniques to facilitate growth are now needed [70]. The CiOQ-S has been designed to be a simple and useful tool for clinical research to researchers and clinicians interested in both the alleviation of psychological distress and the facilitation of positive changes. Third, CiOQ-S might be used to collect data in many different crisis situations in short time.

In summary, the findings from this validation study indicates that the simplified Chinese version of the CiOQ-S is a reliable and valid measure of positive changes and negative changes after adversity and now it can be used in studies of posttraumatic changes in Chinese people. The next step is to use the questionnaire in people traumatised by different events.