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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 6, November/December 2018
368
AFRICA
of Kinanthropometry) level II accredited anthropometrists using
calibrated instruments and standardised methodology to obtain
waist circumference, with inter- and intra-observer variability
less than 10%.
Each participant’s individual coping style (Fig. 2) was
identified with the coping strategy indicator (CSI).
22
The CSI
is a self-report measure consisting of 33 items that determine
whether a person utilises the problem-solving, avoidance, or
seeking-social-support coping style in difficult times. The CSI
demonstrated Cronbach’s alpha (
α
) reliability coefficients of
0.76 to 0.83.
The 33 items in the CSI questionnaire are divided into three
subsets, namely defensive coping (DefS), avoidance/loss of
control, and seeking social support, with 11 items each. A DefS
strategy implies actively solving problems as a defence response,
being in control, and accepting the stressor as reality; seeking
social support implies an active process focused on acquiring
comfort and advice in stressful times; and emotional avoidance
or loss of control implies defeat, with physical and psychological
withdrawal. With a recent stressful event in mind, responders
answered each item using a three-point Likert scale: 3
=
a lot, 2
=
a little; and 1
=
not at all.
The accumulated answers indicate the use of a certain coping
style. A total score of
≥
26 indicated above mean usage of the
problem-solving or active defensive coping style,
≥
23 showed
above-mean use of the social support style, and
≥
19 showed
above-mean use of the avoidance style.
22
For this study, the
following Cronbach’s alphas were calculated: CSI DefS (0.83),
social support (0.88) and avoidance (0.76).
The Africultural coping systems inventory (ACSI) is a 30-item
instrument that tested each participant’s culture-specific coping
behaviours during stressful experiences (Fig. 2). The ACSI was
developed using an African-centred theoretical framework to
analyse coping behaviours of Africans.
14
The ACSI four-factor
orthogonal self-report measure consists of an extensive list of
unique coping behaviours commonly observed among Africans.
Responders answered each item using the following four-point
Likert scale: 0
=
does not apply or did not use; 1
=
used a little, 2
=
used a lot; 3
=
used a great deal.
Participants were asked to think of a stressful situation they
had recently experienced and to respond to the instrument’s items
using the four-point scale. Coping subscales include cognitive/
emotional debriefing (11 items), spiritual-centred coping (eight
items), collectivistic-centred coping (eight items), and ritual-
centred coping (three items). Factor 1, cognitive/emotional
debriefing, represents adaptive and survival-like reactions to
manage perceived environmental stress. Factor 2, spiritual-
centred coping, tests an awareness of spiritual elements in the
cosmos and a sense of connection with the divine. Factor 3,
collectivistic-centred coping, tests respondents’ reliance on group-
centred activities to cope with stressful situations and is grounded
in a culture that values community above the individual. Factor
4, ritual-centred coping, assesses the extent to which participants
use cultural practices such as the performance of rituals, ancestral
worship and acknowledgement of various religious deities.
The ACSI demonstrated adequate internal consistency
reliability for the four subscales, with Cronbach’s alphas ranging
from 0.71 to 0.80.
14
The following Cronbach’s alphas were
calculated: cognitive/emotional debriefing (0.85), spiritual-
centred coping (0.82), collectivistic-centred coping (0.83) and
ritual-centred coping (0.73)
Scores for symptoms of depression were obtained via the
patient health questionnaire depression scale (PHQ-9), which
has been validated in various ethnic groups for use in primary
healthcare settings.
23
Each item evaluated the presence of one of
the nine criteria for major depression from the
Diagnostic and
Statistical Manual of Mental Disorders
, 4th edn (DSM-IV-R).
The Cronbach’s alpha reliability index for the total three-year
PHQ-9 score in the current sub-study was 0.80, indicating good
reliability. The recommended and established PHQ-9 cut-off
point of
≥
10 indicates the presence of depression.
A registered nurse collected fasting serum and plasma samples
using a sterile winged infusion set, after which these samples
were handled according to standardised procedures and frozen
at –80°C until analysis. The
γ
-GT levels were analysed with
the enzyme rate method (KonelabTM 20i, Thermo Scientific,
Vantaa, Finland). Serum cotinine levels were measured using the
homogeneous immunoassay on the Modular Roche automised
analyser (KonelabTM 20i; Thermo Scientific, Vantaa, Finland).
Glycated haemoglobin was measured with the Cobas
®
Integra
400 (Roche, Switzerland), using the turbidimetric inhibition
immunoassay method.
Statistical analysis
Data analyses were completed using the computer software
package Statistica
®
version 13.1 (Dell, TX, USA, 2017). Skewness
of data was tested, and
a priori
covariates were log-normalised if
skewed (age, waist circumference, log physical activity, log
γ
-GT,
Perceived stressor
Primary appraisal
Challenge/threat?
Coping strategy indicator (CSI)
Defensive coping (DefS)
Avoidance/loss of control
Seeking social support
Culture-specific coping strategies (ACSI)
Cognitive/emotional debriefing
Spiritual-centred coping
Collectivistic-centred coping
Ritual-centred coping
Emotional avoidance
(passive coping)
Coping through avoidance,
resulting in withdrawal or
loss of control of a stressor
DefS (active coping)
Coping methods that focus
on control of a perceived
stressor or continuing to
function despite the stressor
Effective
coping
Ineffective
coping
Reappraisal
Fig. 2.
Flow diagram of coping strategies, namely the coping
strategy indicator (CSI),
22
and the Africultural coping
systems inventory (ACSI).
14