Sickness behavior refers to the coordinated set of behavioral alterations caused by inflammatory activation in sick individuals (
Dantzer, 2001). This behavior includes a wide range of symptoms, including malaise, fatigue, fever, anorexia, insomnia, and pain (
Holmes et al., 2011). Previous studies only assessed limited parts of sickness behavior independently, for example, fatigue, anxiety, depressed activities, and physical pain (
Chalder et al., 1993;
Radloff, 1977;
Roberts et al., 1990;
Spitzer et al., 2006;
Stieglitz et al., 2015;
Zwakhalen et al., 2009). Thus,
Andreasson et al. (2018) developed a 10-item self-reporting Sickness Questionnaire (SicknessQ) to measure the comprehensive characteristics of sickness behavior. The development of SicknessQ was divided into three phases. First, a pool of 25 items pertaining to sickness behavior was established on the basis of previous evidence-based literature and team members’ clinical experience. Then, a medical experiment was conducted to select items. Endotoxin or placebo was injected into healthy people to provoke sickness response. Then thirteen responsive items were identified. In the third phase, using a sample consisting of primary care patients, a cross-sectional design revealed a one-factor 10-item SicknessQ with adequate reliability (Cronbach’s alpha = .86), concurrent criterion validity (significantly related to anxiety, depression, and self-rated health), and sensitivity to change.
However, SicknessQ has not been translated from Swedish into languages other than English (
Andreasson et al., 2020), and its applicability to the Chinese context is unclear. A modified version of the English translation of the Sickness Questionnaire that is used in North American populations has suggested that feeling sick is often context dependent, and preliminary evidence showed that sociocultural factors influence how sickness symptoms are defined, given significance, and acted upon (
Shattuck et al., 2020). Different from the Western perspective, traditional Chinese medicine emphasizes “body-mind connection”, which is a holistic viewpoint with the core postulate that the notions of body and mind are mutually dependent yet distinctly different (
Chan et al., 2002). The harmony within the body and the mind is the key to human health. Physical illness and discomfort are concurrently accompanied by weakness, fatigue, and sorrow in the mental aspect. Influenced by this viewpoint, most Chinese people are likely to consciously notice and distinguish functional changes in their body and mind when perceiving their sickness conditions and experience. Therefore, the single-factor SicknessQ may manifest into two distinct factors, namely, physical and mental aspects, in the Chinese cultural context.
In addition, incremental validity is a generic form of criterion validity that indicates whether a new measure adds to the prediction of a criterion beyond what can be predicted by other sources of data, as emphasized in assessment practice by previous researchers (
Hunsley and Meyer, 2003). Predictive validity is a form of criterion validity that shows how well the variable predicts a known criterion, which has been obtained sometime after the variable has been tested. As mentioned, sickness behavior is manifested by various mental and physical symptoms, such as fatigue, pain, and reduced sociability. Studies have shown that mental and physical symptoms are closely related to individual well-being, which is either “hedonia” (feelings or evaluations about pleasure) or “eudaimonia”, that is, flourishing, which is appropriate to the Chinese people, whose culture emphasizes the values of a virtuous and meaningful life, as well as interpersonal relations (
Cheng, 2004;
Tang et al., 2016;
Tsaousis et al., 2007). For example,
Duan and Xie (2019) adopted the Depression Anxiety Stress Scale (DASS) to assess the psychological symptoms of participants. Their results indicated that individuals who had more depression and anxiety symptoms reported less flourishing.
Tong and Wang (2017) also demonstrated that psychological symptoms, such as negative emotional experiences, are negatively correlated with flourishing. Moreover,
Winter et al. (2013) indicated that somatoform disorders significantly reduce people’s well-being. Compared with instruments that independently measure mental or physical symptoms, such as DASS and Screening for Somatoform Symptoms-7, SicknessQ includes a wide range of mental (e.g.
I don’t wish to do anything at all) and physical (e.g.
I have a headache) symptoms. Accordingly, the newly developed SicknessQ is expected to contribute to the explanation of well-being more than the other instruments.
Discussion
This study extended the psychometric properties of SicknessQ in the Chinese social-cultural context. The 9-item SicknessQ-C was demonstrated to be a two-factor structure scale (i.e. physical and mental symptoms) with adequate reliability. Meanwhile, its incremental validity and predictive validity were examined. Specifically, physical and mental symptoms increased the explained variance in flourishing and predicted additional variances of flourishing beyond the pre-existing assessment of negative emotion symptoms after 6 months.
Interestingly, a two-factor structure rather than the original one-factor model was identified in the Chinese context. The difference might be due to the characteristics of validation cohorts across studies. The present study involved samples comprising general community residents and university students, as well as hospitalized university students, and excluded persons with chronic illness. In contrast, in the development and validation of the original instrument,
Andreasson et al. (2018) included healthy participants injected with endotoxin in an experimental study and primary care patients with various disorders. To further evaluate the properties of SicknessQ in an Australian sample,
Andreasson et al. (2020) used a combination of patients and university students (18–25 years old) with chronic medically unexplained symptoms. Variations in age, seriousness of diseases, and kinds of symptoms might have led to the inconsistent factor structures of SicknessQ.
Considering the “body-mind connection” viewpoint popular among Chinese people, the differences in factor structures can be explained by the difference in perspective on the concept of sickness between Eastern and Western cultures. Chinese people usually notice their physical and mental manifestations when reporting their sickness conditions and experience. By contrast, such clear distinction in identifying sickness behavior seems uncommon in the Western perspective (
Andreasson et al., 2018;
Dantzer, 2001). The inconsistent factor structures of the validated instrument in different cultures is not unique. For instance, the Chinese version of Posttraumatic Growth Inventory (
Tedeschi and Calhoun, 1996) has four factors versus the five-factor model of the original English version (
Ho et al., 2004). Character strengths, which comprised six core virtues proposed by
Peterson and Seligman (2004), demonstrated inconsistent factor structures, including five-factor models (
Ruch et al., 2010;
Singh and Choubisa, 2010) and four-factor models (
Brdar et al., 2011) in different cultures, whereas the three-factor structure was found in Chinese culture with qualitative interviews and quantitative data (
Duan and Bu, 2017;
Duan et al., 2012).
We deleted the cross-loading item “
I feel depressed” (Item 5) after factor analysis. Without this item, the model performance in CFA improved, and the ΔR
2 in the two-factor solution (without Item 5) was greater in incremental and predictive validity tests compared with the unidimensional solutions (with or without Item 5). Quantitatively, without Item 5, we obtained a robust structure of sickness behavior among Chinese samples. From the theoretical perspective, excluding this item can be explained in the Chinese cultural context. The feeling of being depressed is regarded as one of the minor mental health problems due to heavy stigmatization of people with mental disorders among the Chinese. The feeling of being depressed is not regarded as sickness but a kind of normal and common life problem by traditional medicine professionals and lay people, which is associated with lifestyle and primarily socially explained (
Kolstad and Gjesvik, 2012). Therefore, the two-factor solution with 9 items seems reasonable.
The incremental and predictive validities demonstrated that SicknessQ-C contributed more in explaining variance of flourishing than DASS. DASS is designed to assess individual emotional or mental symptoms, whereas SicknessQ-C is a more comprehensive method to measure sickness behavior in humans and captures the physical and mental aspects. Hence, SicknessQ-C had stronger incremental validity in predicting individual well-being than tools assessing only one aspect. This finding is plausible and is supported by other studies. For instance, the Brief Inventory of Thriving (BIT) was created to assess comprehensive well-being (
Su et al., 2014), including subjective and psychological well-being, whereas the Satisfaction with Life Scale (SWLS) (
Diener et al., 1985) and Flourishing Scale (
Diener et al., 2010) were used to measure subjective well-being and psychological well-being, respectively. BIT contributed more variance to negative emotions than SWLS and FS (
Duan et al., 2016). Nevertheless, 5.7% and 2.8% (ΔR
2 = .057 and ΔR
2 = .028) are not a large increase in variance.
Cohen (1988) proposed that the average size of the validity increment was about
r = .30 (the square root of the R
2 change value), and studies from various domains have supported this position; most observed relationships fall in the small to medium range (i.e.
r = .10 to .30 or ΔR
2 = .01–.09) (
Haranin et al., 2007;
Meyer, 2000;
Rode et al., 2008). The effects were modest in magnitude but were statistically significant, and the validities under scrutiny were acceptable.
In summary, this study indicated that the 9-item two-factor SicknessQ-C was a reliable and valid measure of sickness behavior among Chinese samples and reflected physical and mental aspects of sickness responses in individuals. In practice, SicknessQ-C can be used as an effective tool to assess mental and physical symptoms caused by inflammatory activity among Chinese. It provides important information and insights into individual sickness situations and promotes further actions and timely treatments.
Several limitations should be addressed. First, our samples were obtained through convenience sampling method. Thus, the generalizability of the results may be limited. A sample that includes both clinical and non-clinical participants is needed in future research to further elucidate the interpretation and reporting of sickness behavior and to lend more evidence to the factor structure and the predictive and incremental validity of the instrument. Second, the study favored a theoretically meaningful two-factor model rather than the unidimensional scale developed by
Andreasson et al. (2018). As we mentioned, this might be partly explained by the difference in perspective on the concept of sickness between Eastern and Western cultures. However, empirical evidence on this kind of cultural difference is lacking. Hence, qualitative material, such as cognitive interviews with individuals and healthcare practitioners about their understanding and interpretation of sickness manifestations, might help. In addition, more samples from similar cultural contexts, such as Hong Kong, Taiwan, and other Asian societies, might offer more evidence to support the two-factor structure. The current study examined the limited aspects of validities, primarily the predictive and incremental validity, in terms of relationships with negative emotion symptoms and flourishing. Other psychometric properties, such as the measurement invariance for SicknessQ-C across groups of diverse characteristics and the convergent and discriminant validities, should be investigated in the future.