Clinical Rehabilitation 2005; 19: 538
/543

Psychometric evaluation of the Energy Conservation

Strategies Survey
Priyanka S Mallik College of Nursing, University of Illinois at Chicago, Marcia Finlayson Department of Occupational
Therapy, University of Illinois at Chicago, Virgil Mathiowetz Program in Occupational Therapy, University of Minnesota,
Minneapolis and Louis Fogg Department of Psychology and College of Nursing, Rush University, Chicago, IL, USA

Received 28th February 2004; returned for revisions 15th April 2004; revised manuscript accepted 8th June 2004.

Objective: To examine the internal consistency and test
/retest reliability of the
Energy Conservation Strategies Survey (ECSS), a tool that was specifically designed
to determine if people with multiple sclerosis who attended the six-week energy
conservation course actually implemented the strategies taught to them.
Design: The instrument ECSS was administered at six weeks and seven weeks post
intervention to evaluate the test
/retest reliability, while data from six weeks post
intervention were utilized to assess the internal consistency of the ECSS.
Setting: Community locations in Illinois and Minnesota, USA.
Subjects: Data from 53 participants with multiple sclerosis living in the community
were utilized for the psychometric study.
Measures: Energy Conservation Strategies Survey.
Results: The internal consistency of 0.92 reveals that all the items are consistent
with each other and measure a single construct. Inferential analyses using intraclass
correlation coefficient indicates good test
/retest reliability (intraclass correlation
coefficient (ICC) /0.79).
Conclusion: Findings of the study suggest that the ECSS exhibits high internal
consistency and good test
/retest reliability. The study implies that the ECSS could
be valuable in measuring changes in behaviour over time among people with multiple
sclerosis after the completion of the six-week energy conservation course provided
by occupational therapists.

Introduction symptoms of multiple sclerosis.2
4 The prevalence

Fatigue is a common symptom for individuals with
multiple sclerosis and is reported as a significant
problem by about 80
/97% of the individuals with
this disease.1 Fatigue is a complex phenomenon
because of its subjectivity, unpredictability and the
way it exacerbates other physical and mental
Address for correspondence: Marcia Finlayson, Department of
Occupational Therapy University of Illinois at Chicago, 1919
West Taylor, Chicago, IL 60612, USA. e-mail: marciaf@uic.edu
# 2005 Edward Arnold (Publishers) Ltd
of fatigue among individuals with multiple sclero-
sis has resulted in extensive research on ways to
lessen the disabling effects of this difficult
symptom.5,7
10
As a part of the therapeutic approach, occupa-
tional therapists routinely deliver energy conserva-
tion education to reduce the impact of fatigue on
the lives of the individuals with multiple sclerosis.11
The ultimate goal in teaching the energy conserva-
tion techniques is to facilitate behaviour change.
However, few studies that have examined the use of
10.1191/0269215505cr789oa
 Evaluation of Energy Conservation Strategies Survey 539

energy conservation techniques3,12 have adminis- study reflected the amendment; so all the partici-
tered an instrument to confirm if participants pants provided informed consent to the psycho-
actually modified their lifestyle in response to metric study by agreeing to volunteer for the
what they learned.13 In addition, those instruments original study.
that have been used are neither widely available in The psychometric study utilized data from 53
the published literature nor have they been sub- participants. A brief summary of key demographic
jected to psychometric evaluation. variables and multiple sclerosis-related character-
The Energy Conservation Strategies Survey istics of these 53 individuals are outlined in
(ECSS) (available from the authors) is designed Table 1.
to identify the energy conservation principles that
individuals with multiple sclerosis utilize after
going through a six-week energy conservation Instrument
education course by Packer et al .14 Since it is a The ECSS is a 14-item self-administered instru-
relatively new survey, no study has yet evaluated ment that measures behaviour outcomes among
its psychometric properties. The purpose of this individuals undergoing the six-week energy con-
study is to evaluate the internal consistency and servation education course by Packer et al .14 ECSS
test
/retest reliability of the ECSS. The specific has a cascading format with two layers of ques-
questions addressed in this paper are: tions (Figure 1). The first question asks the
participant whether he or she carried out a
1) Do individuals’ responses to the questions on particular strategy learned during the energy con-
the ECSS remain stable over a one-week servation course. For this question, the participant
period? responds ‘yes’ or ‘no’. The second part of the
2) Do all the items on the ECSS measure the questioning for a given strategy provides the
same construct? participant the opportunity to elaborate on his or
her yes/no response in more detail. If the ‘yes’ is
selected in the first part, the participant then
chooses the number of changes made or the
frequency of utilization of this strategy. Finally,
Methods Table 1 Summary of demographic characteristics of the
participants (n /53)
The participants were recruited for this study from Characteristics N %
an on-going randomized control trial entitled
‘Energy conservation course for persons with Gender
multiple sclerosis’, funded by the National Multi- Male 11 20.8
Female 42 79.2
ple Sclerosis Society (NMSS) through a grant Ethnic group
awarded to Mathiowetz, Finlayson and Matuska White 51 96.2
in 2001. African-American 1 1.9
Although a number of instruments were admi- No response 1 1.9
nistered in the original study, the psychometric Type of multiple sclerosis
Relapsing/remitting 35 66.0
study only utilized the demographic information at Primary progressive 1 1.9
baseline and the ECSS at six weeks post interven- Secondary progressive 11 20.8
tion. In addition, the psychometric study added a Unknown 6 11.3
second administration of the ECSS one week after Employment status
Full time 11 20.8
the original study administered the tool. The Part time 15 28.3
Institutional Review Board approved this addi- Unemployed 22 41.5
tional data collection point (seven weeks post Retired 5 9.4
intervention) based on an amendment to the Other demographic variables Mean (SD) Range
original study protocol. Informed consent for the Age 49.0 (8.3) 29
/70
Years since symptoms first started 14.0 (9.3) 0
/39
original study was obtained at the face-to-face Years since diagnosed 8.1 (6.3) 0
/24
screening session. The consent form of the original
540 PS Mallik et al.
Figure 1 Model of the ECSS questionnaire.
the participant rates how effective this strategy was
in reducing fatigue.
If ‘no’ is selected for the initial question, the
participant is asked to identify the reason for not
carrying out the particular strategy from the
list that is provided. An ‘other response’ is offered
in case the participant does not find the appro-
priate explanation on the list that is provided on
the survey.
The tool was administered six weeks after the
participants completed the intervention, as some
of the strategies required modification of the
physical environment and/or involvement of family
members. Some of the strategies addressed by the
instrument include: change in work heights; alter-
ing ergonomic positioning of the body; elimination
of the steps of a single task and communication
with family or friends concerning unmet needs.
Analyses
Using the response from the second layer of
ECSS, the outcome variable ‘mean effectiveness ’
was conceptualized. This outcome variable was
derived by calculating the average effectiveness
rating across the strategies a participant identified
as having tried (refer back to Figure 1). In the
second level of ECSS questioning, participants
who identified ‘yes’ to the first level were asked
to identify how effective a strategy had been for
them, using a rating question from 1 to 10 where 1
means not effective and 10 means highly effective
(refer back to Figure 1). It is calculated by
summing the effectiveness scores across all those
that are rated, and the dividing this sum by the
total number of implemented items.
Only the variable ‘mean effectiveness ’ was de-
rived to assess the test
/retest reliability because it
is important to identify the level of effectiveness of
the strategies utilized by the participants rather
than the number of strategies that were implemen-
ted (count of number of ‘yes’ responses from the
first layer of ECSS questioning). In the latter case,
there is always a chance of implementing an item
that is not at all effective in managing fatigue.
All the data for the study were analysed using
version 11.0 of the Statistical Package for the
Social Sciences (SPSS version 11.0).15 The analyses
for the study were completed in a series of defined
stages.
1) Internal consistency : Internal consistency of
the ECSS was analysed using Cronbach’s a. A
Cronbach’s a of 0.8 or greater is considered an
indication of good internal consistency.16 In
addition, the item-to-total correlation coeffi-
cient of B/0.2 is an indication that an indivi-
dual item is not consistent with the overall
scale.6
2) Rank ordering of items : Based on the propor-
tion of ‘yes’ responses for a given item, an
analysis on all the items of ECSS at six weeks
postintervention and seven weeks postinter-
vention was carried out. Spearman’s correla-
tion was carried out to determine if the rank
ordering of the items was stable over time.
 Evaluation of Energy Conservation Strategies Survey 541

3) Test
/retest reliability : Since the data for the Table 2 Cronbach’s a and Item-to-total correlations of items
on the Energy Conservation Strategies Survey (ECSS)
variable ‘mean effectiveness ’ were normally
distributed, test
/retest reliability was evalu- Item no. (yes/no) Item-to-total
ated using paired t-tests and intraclass corre- correlations
lation coefficients (ICC). Paired t-tests were
Time 1 Time 2
carried out and the scores from six weeks
postintervention were compared with the 1. Change in work heights 0.59 0.59
scores from seven weeks postintervention 2. Change in the placement of 0.63 0.74
using p B/0.05. In addition, ICCs were also equipment and tools
3. Operation of adaptive tools and 0.59 0.62
carried out on ‘mean effectiveness ’ at p B/0.05 equipment
level of significance. The formula used for 4. Ergonomic positioning of the body 0.41 0.21
computing ICC is given by Winer’s three-step 5. Elimination of the steps of a single task 0.69 0.41
formula.16 6. Assignment of a task or parts of a task 0.79 0.65
to others
7. Communication for unmet needs 0.68 0.72
Using these strategies, stability over time exists if 8. Modification of an activity 0.78 0.69
the paired t-test is a statistically insignificant p - 9. Setting the priorities 0.64 0.75
value and if the ICC has a value of 0.75 or greater. 10. Simplification of tasks 0.75 0.64
11. Balance work and rest 0.59 0.51
12. Change of time for an activity 0.58 0.50
13. Rests in a day 0.64 0.66
14. Rests during tiring tasks 0.69 0.61
Results Cronbach’s a (reliability coefficient) 0.92 0.89

Consistent with the analysis plan, the results are as
follows:
1) Internal consistency: Cronbach’s a at six
weeks is 0.92 while that at seven weeks is
0.89. All the item-to-total correlations for
both the time points are presented in Table
2. The table clearly shows that all 14 items
represent a single construct. In both cases,
item no. 4 (ergonomic positioning of the
body) was the least consistent at both six
and seven weeks.
2) Rank ordering of items : The analysis of the
rank ordering of items (Table 3) revealed that
item no. 4 (ergonomic positioning of the
body) appeared to be the most commonly
employed strategy by the participants at both
time periods (i.e., high endorsement). Item no.
3 (operation of adaptive tools and equipment)
was the most difficult strategy to implement
by the participants (i.e., low endorsement).
Spearman’s correlation between the rank
ordering of items from six weeks and seven
weeks revealed a strong correlation. This
suggests that the items have been implemented
in the same manner and also suggests that the
level of implementation of items is stable over
time.
3) Test
/retest reliability : Paired t-test at p B/0.05
level of significance revealed that mean effec-
tiveness of the participants across the imple-
mented items was not significantly different at
six weeks and seven weeks with a t-value/
1.687, p -value /0.099, with df/45. ECSS is,
therefore, stable over time as there is appar-
ently no change in the mean effectiveness
reported by participants between the two
time points. ICC coefficient was calculated
and the coefficient of 0.79 supports good
stability over time.
Discussion
Findings of these analyses revealed that the inter-
nal consistency of the instrument is good and that
all items represent the construct of behaviours that
people are supposed to change as a function of the
training. Item no. 4 (‘Whether you have changed
the way you position your body to do an activity’9)
was the least consistent item with an item
/total
correlation of 0.21 at seven weeks post intervention
(lowest item
/total correlation).
There are two potential explanations for the
lower item-to-total correlation for this item. First,
542 PS Mallik et al.

Table 3 Rank ordering of items

Strategy no. Items % ‘yes’ time 1 % ‘yes’ time 2

1 Change in work heights 49.1 58.5

2 Change in the placement of equipments and tools 66.0 71.7
3 Operation of adaptive tools and equipments 43.4 52.8
4 Ergonomic positioning of the body 75.5 86.8
5 Elimination of the steps of a single task 58.5 64.2
6 Assignment of tasks to others 58.5 71.7
7 Communication for unmet needs 64.2 67.9
8 Modification of an activity 64.2 69.8
9 Setting the priorities 66.0 79.2
10 Simplification of tasks 69.8 69.8
11 Balance work and rest 71.7 75.5
12 Change of time for an activity 50.9 56.6
13 Rests in a day 69.8 75.5
14 Rests during tiring tasks 71.7 77.4
Correlation between rank ordering of items for time 1 and time 2 0.87
p B/0.001

this finding may reflect poor item wording, since
currently it may be capturing some other construct
that is loosely tied to behaviours that people are
supposed to change as a function of the training.
Rephrasing the item might make it fit better with
the overall items. Some of the suggestions for
rephrasing are: (a) ‘Whether you have followed
proper body mechanics to do an activity’ or (b)
‘Whether you have consistently maintained correct
body postures to do an activity’.
A second explanation may be statistical in
nature. Since most of the participants implemented
the item, there is very little variability across the
sample for this item. Inadequate variability can
result in low correlation coefficients and this
statistical artefact may also be playing a role in
the low item-to-total correlation.17
Overall, findings of the study suggest that the
participants are making behaviour changes con-
Clinical messages
. ECSS can be used as an outcome tool to
measure behaviour change as a result of
participating in the six-week energy conser-
vation course designed by Packer et al .14
. The use of the ECSS would help therapists
to identify the energy conservation strategies
that clients are having difficulty implement-
ing.
sistent with what is taught in the energy conserva-
tion course. It is interesting to note that item no. 4
(ergonomic positioning of the body) and item no. 3
(operation of adaptive tools and equipment) are
both strategies that relate to ergonomics, yet item
no. 4 (ergonomic positioning of the body) was the
most easily implemented item for participants,
while item no. 3 (operation of adaptive tools and
equipment) was the most difficult item to imple-
ment.
The striking difference across these two items is
consistent with the overall findings that behaviour
changes requiring personal effort are relatively
easy for participants to implement whereas the
items that involve others or require equipment or
physical environment changes are more difficult to
implement. This is also consistent with the findings
of the study by Vanage et al .13 during which this
same implementation pattern was also observed
upon administering the Measuring Change Assess-
ment,14 which records adoption of behaviour
changes after the ‘Managing Fatigue’ course.14
This assessment is the only other tool that was
located that specifically addresses the issues of
behavior change in response to energy conserva-
tion education.
Another explanation for the low implementation
rate of item no. 3 (operation of adaptive tools and
equipment) may be that the participants did not
have an opportunity to try out equipment during
the sessions. The course manual coached the
instructors to distribute catalogues of different
 Evaluation of Energy Conservation Strategies Survey
adaptive equipment instead of displaying and
demonstrating a few to the participants. The
participants might have been more keen to fol-
low-up with this strategy had they been exposed to
the beneficial effects of using some of those
adaptive equipments.
Findings support that the ECSS is stable over
time. Paired t-tests also revealed that there is no
significant change in the way the participants rate
the overall effectiveness of the implemented stra-
tegies across the one-week time-frame. This de-
monstrates that the instrument ECSS has good
test
/retest reliability, which is one of the basic
features of a psychometrically sound instrument.
Future research may want to explore the use of the
energy conservation education and the ECSS with
other populations, for example, people with
chronic fatigue syndrome, rheumatoid arthritis
and fibromyalgia. It would also be valuable to
explore whether the ECSS has utility for other
energy conservation education courses, beyond the
one developed by Packer et al .14
Note : A copy of the Energy Conservation
Strategies Survey can be obtained by contacting
Dr Mathiowetz at mathi003@umn.edu
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