Clinical Rehabilitation 2007; 21: 912–922

Development of a Chinese version of the Modified

Barthel Index – validity and reliability
Sharron OC Leung Occupational Therapy Department, Caritas Medical Centre, Chetwyn CH Chan Department of
Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China and Surya Shah Departments of
Neurology and Occupational Therapy, University of Tennessee Health Science Center, USA

Received 9th August 2006; returned for revisions 9th September 2006; revised manuscript accepted 15th December 2006.

Objective: To establish the structural validity of the Chinese version of the Modified
Barthel Index and to estimate its inter-rater reliability for use with patients who have
had a stroke.
Design: Prospective study.
Setting: A regional general hospital and a day hospital in Hong Kong.
Subjects: One hundred and sixteen older people who had had a stroke (mean age
76.0; SD 7.6) were involved in the establishment of evidence of the structural validity
and item quality. Another 15 older people with stroke (mean age 78.0; SD 7.1)
participated in estimating the reliability of the instrument.
Methods and results: The Modified Barthel Index was translated into Chinese.
Factor analyses revealed a two-factor structure that explained 75.7% of the total
variance. Factor 1 was found to consist of eight items relating to patients’ functional
performance. Factor 2 consisted of the two items that focused on patients’
‘physiological needs’. The test–retest reliability of the Chinese version at the item
level was comparable with that of the original version, with kappa statistics ranging
from 0.63 to 1.00 (P < 0.001).
Conclusion: The Chinese version of the Modified Barthel Index (MBI-C) seems to be
valid and reliable for use with older people with stroke. Changes were made to the
item content and the rating criteria that were specific to Chinese culture. The struc-
tural validity and the reliability of the Chinese version were shown to be robust across
the original and Chinese groups.

Introduction dependency needs that can assist clinicians to

make decisions about a person’s discharge plan
Independence in self-care activities is a common and follow-up care requirements.2,3 The most
outcome measure used in rehabilitation of people common method used for assessing a person’s
with stroke. It reflects the impact of physical self-care performance is through the use of a stan-
impairment on the functioning of an individual.1 dardized measure consisting of a set of well-
At the same time, it offers an objective data on the defined tasks. The Barthel Index is one of the
most widely used measures of self-care perfor-
mance. Among all other instruments, the Barthel
Address for correspondence: Professor Chetwyn CH Chan, Index has been regarded as the best in terms of its
Department of Rehabilitation Sciences, The Hong Kong
Polytechnic University, Hung Hom Kowloon, Hong Kong sensitivity, simplicity, communicability, scalability
SAR, China. e-mail: [email protected] and ease of scoring.4–14 Because of these, the
ß SAGE Publications 2007
Los Angeles, London, New Delhi and Singapore 10.1177/0269215507077286

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 Chinese Barthel Index 913

Barthel Index has become the common instrument complexity and hence the demands on the people
used by both clinicians and researchers in the field when performing the test items among the four
of rehabilitation.3,15–19 cultural groups. Similarly, Kucukdeveci et al.24
The Barthel Index was first published in 1965 identified a need for item description modifica-
and consists of 10 items: personal hygiene, bath- tions to minimize certain degree of irrelevance of
ing, feeding, toileting, stair climbing, dressing, the test items when applying them to the Turkish
bowel control, bladder control, ambulation or culture.
wheelchair and chair–bed transfer.11 A person’s Previous studies conducted on Chinese popula-
performance is rated on an arbitrary two- to tions have identified similar needs to redefine cul-
four-point scale depending on the amount of phy- turally loaded items such as eating, bathing and
sical assistance required and the social significance climbing stairs.25,26 These concerns about items
of the tasks. The item scores range from ‘0’, which relating to personal care were attributable to cul-
indicates an inability to perform, to a maximum of tural style and habit, whilst the item relating to
‘5, 10 or 15’, which represents total independence. mobility was attributable to the constraints
The total items score of 100 indicates complete imposed by the unique physical environment.
independence in self-care performance. In consultation with the developer of the MBI, a
The validity and reliability of this version translation by the linguistic division of the MAPI
has been reported for use in people with stroke Research Institute in 2006 incorporated modifica-
and hip fractures, and for predicting the risk of tions of the descriptions of the item tasks and their
falls.12–14 More recently, Shah et al.8 further rating criteria for a nine-nation study to be con-
improved the discriminative power of the instru- ducted by Merck & Co.27 The purpose of this
ment by standardizing the rating criteria and scale study was to establish the psychometric evidence
into a five-point Likert format. Other versions for the Chinese version of the MBI after transla-
include the 10-point hierarchical20 and extended tion from its original English version. This
Barthel Index.21 The Modified Barthel Index included testing its content relevance with respect
(MBI), as it is known, has increased the sensitivity to Chinese culture in Hong Kong. The structural
of the instrument both at the item and scale levels, validity and item quality were evaluated, and the
and yielded a higher content reliability and inter- inter-rater reliability and internal consistency were
nal consistency.4,8,22 estimated.
A review of the literature on the Barthel Index As the MBI has been adopted as the major clin-
or MBI indicates that most of the studies were ical instrument in Chinese clinical and rehabilita-
conducted in non-Chinese countries and the litera- tion research settings,28 the findings of this present
ture was published in English. This leads us to study could further enhance its utilization among
question to what extent the different versions of the Chinese patient population and in cross-cul-
Barthel Index (or MBI) can be applied for use tural comparisons.
among the Chinese population. Potential threats
to the validity and reliability might exist when the
instrument is translated into Chinese or used in
different physical environments such as stairs. Method
These threats may lead to patients with the same
level of functional independence ending up with The MBI was first translated into Chinese. The
different scores on the Barthel Index. Shah translation included converting the task descrip-
et al.23 conducted a cross-cultural comparison of tions and rating criteria of the original MBI into
the level of independence of post-stroke patients Chinese using a qualified linguist. The translation
using the MBI between Australia, Japan, the UK process adopted an idiomatic method together
and the USA. The results of this study revealed with an emic approach. The translated version
significant differences in the rank orders of the was then reviewed by an expert panel for its
10 items across the four countries. The authors equivalence to the original version. The reviews
also suggested that the differences were probably included a description of each test task item and
due to the relative discrepancies in the task the definitions of the performance criteria

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914 SOC Leung et al.

specified in the rating scale of that item. The Data analysis

results of the expert panel review indicated a The evidence for structural validity was
high content equivalence between the translated established using exploratory factor analysis to
Chinese and the original versions of the MBI. identify the latent factors underlying the 10
However, the expert panel identified a few cul- Chinese version MBI items. Item analyses
ture-specific components that had not been incor- were also conducted to obtain the item
porated into the descriptions of the original task difficulty and discriminative indices for each of
contents. These components centred around the items.29
personal style and habits, constraints imposed by
the local living and community environment.
Modifications were made to individual items
with reference to the experts’ opinions to compose Inter-rater reliability and internal consistency
the finalized Chinese version of the MBI Sample and procedure
(Appendix 1). This version was then used to test Fifteen patients with stroke were recruited ran-
its structural validity, item quality and inter-rater domly from the stroke rehabilitation programme
reliability. of Caritas Medical Centre by drawing lots. The
inclusion criteria were similar to those of the pre-
vious section. There were eight women (53%) and
Structural validity
seven men (47%), with a mean age of 78 years
Sample and procedure
A total of 116 people with stroke were selected (SD ¼ 7.1). There were four occupational thera-
at random from the stroke rehabilitation pro- pists working in the Caritas Medical Centre who
gramme operating in the Caritas Medical Centre. volunteered to participate in this part of the study.
The method used for randomization was to draw The raters were randomly divided into two pairs:
lots when the patients entered the predischarge each pair had one male and one female therapist
planning stage throughout the data collection with experience of working in elderly rehabilita-
period. Sixty (52%) were male and 56 (48%) tion. The first pair of raters was trained to
were female. All of them were diagnosed with administer the original MBI, whilst the
first stroke as confirmed by a CT scan. second pair of raters was trained to administer
Fifty-nine (51%) had left-sided hemiplegia, 49 the Chinese version of the MBI. In each
(42%) had right-sided hemiplegia, and the remain- assessment, there was one key rater and three
ing eight (7%) were bilateral. Their mean age was observing raters. Each rater took a turn
76 years (SD ¼ 7.6) and the mean length of stay being the key rater, and led the assessment by
was 29.3 days, ranging from 6 to 71 days. instructing the participating person to perform
Six occupational therapists working in the reha- each of the 10 test tasks. The observing
bilitation units of the same hospital participated raters were present at the time of the assessment,
voluntarily in rating this part of the study. The but made observations on the person’s perfor-
therapists received training from the first author mance and scored according to either the original
of this paper on the administration of the trans- or Chinese version MBI protocol. The chance of
lated version of the MBI. People who entered into serving as the key rater was more or less the same
the predischarge planning stage were referred to across the four raters.
one of the raters for assessment. The raters did
not have prior information on the patient’s
medical history or on the self-care performance
at the time of the assessment. As each of the Data analysis
participating therapists had their own clinical The inter-rater reliability was estimated
load, the matching between the patients and the using kappa statistics at the item level and
raters was done by a convenience method, but the Cronbach’s alpha was used to estimate the internal
number of assessments conducted was evenly consistency of both the original and Chinese
distributed among the raters. versions.30

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 Chinese Barthel Index 915

Table 1 Factor loadings of Chinese version Modified Table 2 Results of item analyses on Chinese version
Barthel Index items Modified Barthel Index items – difficulty and discriminative
indices
MBI-C items Factor 1 Factor 2
MBI-C items Difficulty index Discriminative index
Dressing 0.924 0.011
Ambulation 0.921 0.028 Feeding 0.91 0.54
Toileting 0.910 0.039 Bowel control 0.86 0.57
Stair climbing 0.885 0.088 Bladder control 0.81 0.58
Transfer 0.874 0.183 Personal hygiene 0.77 0.80
Bathing 0.869 0.080 Transfer 0.74 0.90
Personal hygiene 0.810 0.176 Dressing 0.64 0.89
Feeding 0.513 0.198 Toileting 0.61 0.89
Bowel control 0.369 0.846 Ambulation 0.60 0.91
Bladder control 0.387 0.835 Bathing 0.44 0.81
Stair climbing 0.31 0.84

The difficulty index is defined as the mean item score divided

by the total item score (which is 5); the discriminative index is
Results the item-to-total-score correlation.

Structural validity and item quality

A total of 116 older people post stroke were moment correlation coefficient. Any coefficients
administered the Chinese version of the MBI greater than 0.28 are considered as having a
(MBI-C) after they entered into the predischarge satisfactory discrimination property.31,32
phase of the stroke rehabilitation programme. The item discriminative indices of the MBI-C
Their mean MBI-C total score was 67.4 items ranged from 0.54 to 0.91. The most
(SD ¼ 21.6) with a range between 12 and 100. discriminative item was ‘ambulation’ (r ¼ 0.91)
The data obtained were analysed with exploratory whilst the least discriminative item was ‘feeding’
factor analysis using a principal component (r ¼ 0.54).
method for extracting the latent factors, followed
by quartimax with the Kaiser normalization
method for rotating the identified factors. The
Inter-rater reliability and internal consistency
Kaiser–Meyer–Olkin measure was 0.904, suggest- Two sets of inter-rater reliability indices were
ing a sample adequacy, and Bartlett’s test for obtained by conducting the MBI-C and the MBI
sphericity was significant (P < 0.0001), indicating concurrently on a total of 15 people with stroke.
the appropriateness of the factor model. All factor The mean total scores on the MBI-C and the MBI
loadings were above 0.30. The results suggested a were similar. These scores were 57.2 (SD ¼ 20.4)
two-factor solution, which explained 75.7% of the and 60.5 (SD ¼ 22.3) respectively. The kappa
total variance (Table 1). Eight items were grouped values, as a measure of inter-rater reliability
under factor 1, the item contents of which were between a pair of raters at an item level for the
more related to self-care functioning. Two items, MBI-C, were between 0.81 and 1.00 (Table 3). All
‘bowel control’ and ‘bladder control’, were pairs of raters were regarded as having excellent
grouped under a separate factor 2, the task con- inter-rater consistency (k-values >0.80).30
tents of which were more related to the ‘physiolo- The most inter-rater consistent item among the
gical needs’ of the patients. MBI-C items was ‘transfer’ (k ¼ 1.00) whilst the
The results of the item analyses revealed dif- least consistent item was ‘stair climbing’ (k ¼ 0.81).
ficulty indices (item mean divided by total item In contrast, the inter-rater reliability coefficients
score) 30 of the 10 items ranging between 0.31 for the MBI items were between 0.63 and 0.85.
and 0.91 (Table 2). The most difficult item was The most inter-rater consistent item was ‘personal
‘stair climbing’ (0.31) whilst the easiest item was hygiene’ (k ¼ 0.85) whilst the least consistent item
‘feeding’ (0.91). The discriminative index is the was ‘toileting’ (k ¼ 0.63). Among the MBI items,
item-to-total correlation using Pearson’s product only six items were regarded as having excellent

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916 SOC Leung et al.

Table 3 Inter-rater reliability and internal consistency of the Psychometric properties of the MBI-C
Chinese and original versions of Modified Barthel Index Our findings reveal two latent factors under
Items MBI-Ca MBIa which the 10 items were grouped. These findings
were found to be consistent with two others
Feeding 0.87 0.84 studies. The study conducted by Tennant et al.33
Transfer 1.00 0.82 indicated a less than satisfactory fit between the
Personal hygiene 0.91 0.85
Toileting 0.90 0.63 Barthel Index and the unidimensional model, as
Bathing 0.81 0.81 tested with Rasch analysis. Among the items the
Ambulation 0.90 0.80 authors identified the ‘bladder control’ item,
Stair climbing 0.81 0.79 which had a deviated INFIT value score. This
Dressing 0.83 0.78
Bowel control 0.91 0.78
suggests that the item did not follow the same
Bladder control 0.91 0.82 trend as the rest of the items when a single-dimen-
Internal consistencyb 0.93 0.92 sion model was imposed onto the data.
Kucukdeveci et al.24 revealed similar results for
a
b
All are kappa values with a significance level of P < 0.001. the MBI in that the ‘bladder control’ and ‘bowel
Cronbach alpha coefficients. control’ items were found to misfit the single-
MBI-C, Chinese version of the Modified Barthel Index; MBI,
original version of the Modified Barthel Index. dimension model. In this study, the sample was
made up of older people who had had a stroke.
The difficulty indices of these two items (0.86 and
0.81; see Table 3) suggested that the patients gen-
erally had very good control of both the bowel and
inter-rater consistency (k-values >0.80). The bladder function. As impairments to the bowel
internal consistency, estimated using Cronbach’s and the bladder are not common problems
alpha, was similar between the MBI-C and the caused brain lesions following a stroke, the
MBI. The alpha value for the former was 0.93 between-individual variation of patients’ ratings
(P
0.001) while for the latter it was 0.92 on these two items should be small. The relatively
(P
0.001). high scores and small variances of these two items
are plausible reasons for the two-factor structure
of the MBI-C. Further studies should focus on
investigating the stability of the two-factor struc-
Discussion ture across different diagnostic groups and its
impact on compromising the advantage of using
the total score instead of an eight-item Self-care
This aim of this study was to translate the original function subscale score and a two-item
Modified Barthel Index into a Chinese version, Physiological function subscale score.
and to establish psychometric evidence for its use The inter-rater reliability was found to be satis-
with older persons following a stroke. In general, factory for the MBI-C. In several items, the
the Chinese version of the MBI was found to have Chinese version items appear to have higher
good validity and reliability for use in the stroke inter-rater consistency than those of the original
population. The findings indicate that when version. The improvements in the inter-rater relia-
adapting the MBI for use in assessing Chinese bility can probably be attributed to the modifica-
patients, there are culture-specific contents that tions made to the task content and refinements
were required to be incorporated into the original made to the rating criteria so as to make the vali-
items. If not properly dealt with, the item ambi- dated instrument more relevant for use among
guity could pose potential threats to the psycho- Chinese patients. The internal consistency of the
metric properties of the instrument. The items items in the Chinese version was found to be high
showed satisfactory item quality and good inter- and comparable to that of the original version.
rater reliability. The high internal consistency of This further indicates that internal consistency
the Chinese version was comparable with that of could be a good indicator of the reliability of the
the original version. clinical instrument.

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 Chinese Barthel Index 917

Cultural issues embedded in measurement of the threat to the content validity when utilizing
functional independence the test among Chinese patients.
As self-care activities are susceptible to the per- The content ambiguity identified in the ‘stair
sonal style and habits of people, the content of climbing’ task is a good example of how the phy-
each task carries a heavy culture component. sical environment could have imposed threats to
The most obvious example of the difference the validity of the MBI. According to the opinions
between the personal style and habits of Chinese gathered from the experts, the most common
people and those of westerners is on the item living environment in Hong Kong is a flat in a
‘feeding’. Older Chinese people commonly use multi-storey building that has direct lift access.
chopsticks and a spoon for eating whereas their If people have to climb the stairs, there are
western counterparts use a knife and fork. The two flights of stairs (each with eight steps) rather
results are consistent with other cultures that use than one flight of 13 steps as stipulated in
chopsticks, such as the Japanese. Shah et al.23 sug- the original MBI. As with the ‘feeding’ item,
gested using a pair of chopsticks to replace a knife ‘stair climbing’ needs to be modified both
and fork for people with a Japanese background. in terms of its task content and rating criteria
The other examples are seen in the items (particularly when patients are required to
‘toileting’ and ‘bathing’. The expert review of climb stairs).
this study suggested that older Chinese people
tended to use various methods and gadgets for
intestinal cleansing and satisfying their toileting
and bathing needs. For instance, some of them Limitations
used both a sitting-type and a squatting-type The psychometric properties established for the
toilet instead of just the sitting-type toilet as com- Chinese version of the MBI in this study are based
monly used by westerners. Some also preferred a on a group of older patients post stroke at the
towel (or sponge) bath while sitting on a low stool predischarge stage. Despite the established
and using a basin of water rather than a tub-bath portability of the original MBI, the results
obtained may not be readily generalizable to
or a shower. In Japan, individuals might bathe in a
other age and diagnostic groups. Similarly, the
deep bath tub with high walls, which requires
two-factor structure revealed is probably diagnos-
climbing and squatting.23
tic-group specific, and may have been different if
The implications of the culture-specific differ-
the sample group had consisted of patients with a
ences in the task content are that the task descrip-
spinal cord injury (with compromised bowel and
tions in the original MBI do not necessarily
bladder functions). Readers should therefore be
translate directly when defining the task process
cautious when interpreting the results. Further
of the same tasks normally performed by studies should explore the stability of the struc-
Chinese people. These differences would also tural validity across different age and diagnostic
lead to differences in the task difficulty and groups.
hence the rating criteria. For instance, manipulat- Another limitation is the small sample size
ing a pair of chopsticks is more difficult than using used to estimate the inter-rater reliability,
a fork for picking up food. The physical demands which may have lowered the power of the
to obtain an independence rating on the ‘feeding’ analysis and hence the reliability coefficients.
item would require higher finger dexterity and The personal style and habits, and the physical
upper limb coordination from Chinese subjects environment are specific to Hong Kong, which
(manipulating a pair of chopsticks) than from is a relatively small city within the larger China
their western counterparts (holding a fork). This and Chinese context. Finally, the patients parti-
could explain why the rank order of items was cipating in this study, although randomly
previously found to differ across different cultural selected, were mainly recruited from the two
groups.23,24 centres located in the Kowloon West region.
Nevertheless, modifications of the task content The representativeness of this group cannot be
descriptions and rating criteria should minimize established. Researchers and clinicians should

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918 SOC Leung et al.

10 Sangha H, Lipson D, Foley N et al. A comparison

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Appendix 1 – Chinese version of the Modified Barthel index

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 Chinese Barthel Index 921

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922 SOC Leung et al.

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