Supportive Care in Cancer

, Volume 25, Issue 2, pp 633–643 | Cite as

Psychometric properties and measurement equivalence of the English and Chinese versions of the Beck Anxiety Inventory in patients with breast cancer

  • Yu Ke
  • Terence Ng
  • Hui Ling Yeo
  • Maung Shwe
  • Yan Xiang Gan
  • Alexandre Chan
Original Article



There is a lack of psychometric data for both the English and Chinese versions of Beck Anxiety Inventory (BAI) to support its usage among breast cancer patients. This study examined the psychometric properties and measurement equivalence of the English and Chinese versions of BAI among breast cancer patients in Singapore.


Patients were recruited from two major cancer centers in Singapore. The criterion and construct validity of BAI was assessed by its correlation strength with (1) the emotional functioning subdomain of EORTC QLQ-C30 and (2) constructs related to anxiety, namely fatigue, dyspnea, and quality of life. The known-group validity was assessed according to the patients’ breast cancer stage, religious beliefs, and emotional functioning levels. The internal consistency of the BAI domains was evaluated using Cronbach’s alpha coefficient. Regression analysis was performed to compare the BAI total and domain scores between the two language versions.


Data from 244 patients (144 English-speaking and 100 Chinese-speaking) were analyzed. For both language versions, the BAI total scores correlated moderately with the EORTC QLQ-C30 emotional functioning subdomain (r = −0.655 and −0.601). Correlations with fatigue, quality of life, and dyspnea were moderate (|r| = 0.456–0.606). Patients with poorer emotional functioning reported higher anxiety levels, establishing known-group validity. All BAI domains demonstrated satisfactory internal consistencies (α = 0.74–0.87), except for the panic domain (α = 0.57–0.61). Possible measurement equivalence between the language versions was established.


Both English and Chinese versions of BAI are valid, reliable, and possibly equivalent for future use.


Cancer Oncology Anxiety Beck anxiety inventory Measurement equivalence Validation 



The authors would like to thank the patients for their participation in this study. This study was financed by a research grant awarded by the National Medical Research Council Singapore (NMRC/CIRG/1386/2014).

Compliance with ethical standards

This study was approved by the SingHealth Institutional Review Board.

Conflict of interest

The authors declare that they have no competing interests.


  1. 1.
    Baqutayan SMS (2012) The effect of anxiety on breast cancer patients. Indian journal of psychological medicine 34(2):119–123CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Pedersen AE, Sawatzky J-A, Hack TF (2010) The sequelae of anxiety in breast cancer: a human response to illness model. Oncol Nurs Forum 37(4):469–475CrossRefPubMedGoogle Scholar
  3. 3.
    Burgess C, Cornelius V, Love S et al (2005) Depression and anxiety in women with early breast cancer: five year observational cohort study. BMJ: British Medical Journal 330(7493):702–705CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    So WKW, Marsh G, Ling WM et al (2010) Anxiety, depression and quality of life among Chinese breast cancer patients during adjuvant therapy. Eur J Oncol Nurs 14(1):17–22CrossRefPubMedGoogle Scholar
  5. 5.
    Schreier AM, Williams SA (2004) Anxiety and quality of life of women who receive radiation or chemotherapy for breast cancer. Oncol Nurs Forum 31(1):127–130CrossRefPubMedGoogle Scholar
  6. 6.
    Spiegel D, Riba MB (2015) Managing anxiety and depression during treatment. Breast J 21(1):97–103CrossRefPubMedGoogle Scholar
  7. 7.
    Stark D, Kiely M, Smith A et al (2004) Reassurance and the anxious cancer patient. Br J Cancer 91(5):893–899PubMedPubMedCentralGoogle Scholar
  8. 8.
    Jones SL, Hadjistavropoulos HD, Gullickson K (2014) Understanding health anxiety following breast cancer diagnosis. Psychology, health & medicine 19(5):525–535CrossRefGoogle Scholar
  9. 9.
    Cheung YT, Lee HH-L, Chan A (2013) Exploring clinical determinants and anxiety symptom domains among Asian breast cancer patients. Support Care Cancer 21(8):2185–2194CrossRefPubMedGoogle Scholar
  10. 10.
    Julian LJ (2011) Measures of anxiety: state-trait anxiety inventory (STAI), Beck Anxiety Inventory (BAI), and hospital anxiety and depression scale-anxiety (HADS-A). Arthritis Care Res (Hoboken) 63(Suppl 11):S467–S472CrossRefGoogle Scholar
  11. 11.
    Beck AT, Epstein N, Brown G, Steer RA (1988) An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol 56(6):893–897CrossRefPubMedGoogle Scholar
  12. 12.
    Fydrich T, Dowdall D, Chambless DL (1992) Reliability and validity of the Beck anxiety inventory. Journal of Anxiety Disorders 6(1):55–61CrossRefGoogle Scholar
  13. 13.
    de Beurs E, Wilson KA, Chambless DL et al (1997) Convergent and divergent validity of the Beck Anxiety Inventory for patients with panic disorder and agoraphobia. Depression and anxiety 6(4):140–146CrossRefPubMedGoogle Scholar
  14. 14.
    Wetherell JL, Areán PA (1997) Psychometric evaluation of the Beck Anxiety Inventory with older medical patients. Psychol Assess 9(2):136–144CrossRefGoogle Scholar
  15. 15.
    Osman A, Barrios FX, Aukes D et al (1993) The Beck anxiety inventory: psychometric properties in a community population. J Psychopathol Behav Assess 15(4):287–297CrossRefGoogle Scholar
  16. 16.
    Osman A, Kopper BA, Barrios FX et al (1997) The Beck anxiety inventory: reexamination of factor structure and psychometric properties. J Clin Psychol 53(1):7–14CrossRefPubMedGoogle Scholar
  17. 17.
    Creamer M, Foran J, Bell R (1995) The Beck Anxiety Inventory in a non-clinical sample. Behav Res Ther 33(4):477–485CrossRefPubMedGoogle Scholar
  18. 18.
    Magán I, Sanz J, García-Vera MP (2008) Psychometric properties of a Spanish version of the Beck Anxiety Inventory (BAI) in general population. The Spanish journal of psychology 11(2):626PubMedGoogle Scholar
  19. 19.
    Yap KY-L, Low XH, Chui WK et al (2012) Computational prediction of state anxiety in Asian patients with cancer susceptible to chemotherapy-induced nausea and vomiting. J Clin Psychopharmacol 32(2):207–217CrossRefPubMedGoogle Scholar
  20. 20.
    Luo N, Thumboo J (2004) Factors influencing health-related quality of life of Asians with anxiety disorders in Singapore. Qual Life Res 13(2):557–565CrossRefPubMedGoogle Scholar
  21. 21.
    Fayers PM, Machin D (2000) Quality of life: assessment, analysis and interpretation. John Wiley & Sons, Chichester; SingaporeCrossRefGoogle Scholar
  22. 22.
    Aaronson NK, Ahmedzai S, Bergman B et al (1993) The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 85(5):365–376CrossRefPubMedGoogle Scholar
  23. 23.
    Luo N (2005) The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30): validation of English version in Singapore. Qual Life Res 14(4):1181–1186CrossRefPubMedGoogle Scholar
  24. 24.
    Zhao H (2000) Translation and validation of the standard Chinese version of the EORTC QLQ-C30. Qual Life Res 9(2):129–137CrossRefPubMedGoogle Scholar
  25. 25.
    Shih C-L, Chen C-H, Sheu C-F et al (2013) Validating and improving the reliability of the EORTC qlq-c30 using a multidimensional Rasch model. Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research 16(5):848–854CrossRefGoogle Scholar
  26. 26.
    Kontodimopoulos N, Ntinoulis K, Niakas D (2011) Validity of the Greek EORTC QLQ-C30 and QLQ-BR23 for measuring health-related quality of life in breast cancer patients. European Journal of Cancer Care 20(3):354–361CrossRefPubMedGoogle Scholar
  27. 27.
    Taylor R (1990) Interpretation of the correlation coefficient: a basic review. Journal of Diagnostic Medical Sonography 6(1):35–39CrossRefGoogle Scholar
  28. 28.
    So WKW, Marsh G, Ling WM et al (2009) The symptom cluster of fatigue, pain, anxiety, and depression and the effect on the quality of life of women receiving treatment for breast cancer: a multicenter study. Oncol Nurs Forum 36(4):E205CrossRefPubMedGoogle Scholar
  29. 29.
    Bodtcher H, Bidstrup PE, Andersen I et al (2015) Fatigue trajectories during the first 8 months after breast cancer diagnosis. Qual Life Res 24(11):2671–2679CrossRefPubMedGoogle Scholar
  30. 30.
    De Vries J, Vd S, der Ent FWC V, JA R (2006) Trait anxiety predicts fatigue in women with early stage breast cancer. EJC Suppl 4(2):91–92CrossRefGoogle Scholar
  31. 31.
    Vahdaninia M, Omidvari S, Montazeri A (2010) What do predict anxiety and depression in breast cancer patients? A follow-up study. Soc Psychiatry Psychiatr Epidemiol 45(3):355–361CrossRefPubMedGoogle Scholar
  32. 32.
    Jd V, Roukema JA, Mertens MC et al (2013) Cancer or no cancer: the influence of trait anxiety and diagnosis on quality of life with breast cancer and benign disease: a prospective, longitudinal study. World J Surg 37(9):2140–2147CrossRefGoogle Scholar
  33. 33.
    Leivseth L, Nilsen TIL, Mai X-M et al.. Lung function and anxiety in association with dyspnoea: the HUNT study. Respir Med 106(8):1148–1157Google Scholar
  34. 34.
    Cheung YT, Lim SR, Shwe M et al (2013) Psychometric properties and measurement equivalence of the English and Chinese versions of the functional assessment of cancer therapy-cognitive in Asian patients with breast cancer. Value Health 16(6):1001–1013CrossRefPubMedGoogle Scholar
  35. 35.
    Mutchnick MG, Williams JM (2012) Anxiety and memory test performance. Applied neuropsychology Adult 19(4):241CrossRefPubMedGoogle Scholar
  36. 36.
    Cronbach LJ (1951) Coefficient alpha and the internal structure of tests. Psychometrika 16(3):297–334CrossRefGoogle Scholar
  37. 37.
    Chadwick D (2001) Monotherapy comparative trials: equivalence and differences in clinical trials. Epilepsy Res 45(1):101–103CrossRefPubMedGoogle Scholar
  38. 38.
    Jones B, Jarvis P, Lewis JA, Ebbutt AF (1996) Trials to assess equivalence: the importance of rigorous methods. BMJ: British Medical Journal 313(7048):36–39CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Herdman M, Fox-Rushby J, Badia X (1998) A model of equivalence in the cultural adaptation of HRQoL instruments: the universalist approach. Qual Life Res 7(4):323–335CrossRefPubMedGoogle Scholar
  40. 40.
    Cheung YB, Thumboo J, Goh C et al (2004) The equivalence and difference between the English and Chinese versions of two major, cancer-specific, health-related quality-of-life questionnaires. Cancer 101(12):2874–2880CrossRefPubMedGoogle Scholar
  41. 41.
    Cohen J (1988) Statistical power analysis for the behavioral sciences. L. Erlbaum Associates, Hillsdale, N.JGoogle Scholar
  42. 42.
    Zwingmann C, MüLler C, Körber J, Murken S (2008) Religious commitment, religious coping and anxiety: a study in German patients with breast cancer. European Journal of Cancer Care 17(4):361–370CrossRefPubMedGoogle Scholar
  43. 43.
    Shiah Y-J, Chang F, Chiang S-K et al (2015) Religion and health: anxiety, religiosity, meaning of life and mental health. J Relig Health 54(1):35–45CrossRefPubMedGoogle Scholar
  44. 44.
    McCoubrie RC, Davies AN (2006) Is there a correlation between spirituality and anxiety and depression in patients with advanced cancer? Support Care Cancer 14(4):379–385CrossRefPubMedGoogle Scholar
  45. 45.
    Gioiella ME, Berkman B, Robinson M (1998) Spirituality and quality of life in gynecologic oncology patients. Cancer Pract 6(6):333–338CrossRefPubMedGoogle Scholar
  46. 46.
    Verburg K, Griez E, Meijer J, Pols H (1995) Respiratory disorders as a possible predisposing factor for panic disorder. J Affect Disord 33(2):129–134CrossRefPubMedGoogle Scholar
  47. 47.
    Higginson IJ, Costantini M (2008) Dying with cancer, living well with advanced cancer. Eur J Cancer 44(10):1414–1424CrossRefPubMedGoogle Scholar
  48. 48.
    Paiva CE, Carneseca EC, Barroso EM et al (2014) Further evaluation of the EORTC QLQ-C30 psychometric properties in a large Brazilian cancer patient cohort as a function of their educational status. Support Care Cancer 22(8):2151–2160PubMedGoogle Scholar
  49. 49.
    Pamuk GE, Harmandar F, Ermantaş N et al (2008) EORTC QLQ-C30 assessment in Turkish patients with hematological malignancies: association with anxiety and depression. Ann Hematol 87(4):305–310CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Yu Ke
    • 1
  • Terence Ng
    • 1
  • Hui Ling Yeo
    • 1
  • Maung Shwe
    • 1
  • Yan Xiang Gan
    • 2
  • Alexandre Chan
    • 1
    • 2
    • 3
  1. 1.Department of PharmacyNational University of SingaporeSingaporeSingapore
  2. 2.Department of PharmacyNational Cancer Centre SingaporeSingaporeSingapore
  3. 3.Duke-NUS Graduate Medical School SingaporeSingaporeSingapore

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