Translating health status questionnaires and evaluating their quality: the IQOLA Project approach. International Quality of Life Assessment

Correlates of satisfaction for the relationship with their physician in type 2 diabetic patients

In the context of an Italian nation-wide outcomes research program on type 2 diabetes, we investigated the contribution of both patient and setting-related factors to patient satisfaction with their relationship with their physicians. The level of patient satisfaction was measured using the American Board of Internal Medicine (ABIM) 14 patient satisfaction questionnaire. The main results were obtained using multilevel analysis, a statistical technique that takes into account the clustered nature of our data. Overall, 3563 patients were recruited by 101 diabetologists and 103 general practitioners (GPs). Information on patients' satisfaction was available for 2515 patients (71% of the whole sample). Patients' satisfaction was related to patient characteristics and attitudes, but not with physician's sex, age, speciality, and setting of care. In particular, patients who were less likely to delegate to physicians responsibility for diabetes management and those perceiving a lower degree of involvement in disease management showed lower levels of satisfaction. Lower satisfaction scores were also related to lower levels of school education, more severe clinical conditions, and lower psychological adaptation to diabetes. However, patients reporting higher levels of diabetes related worries and more frequent encounters with health care providers showed higher levels of satisfaction. In conclusion, patient satisfaction with physicians' humanness and communication skills is strongly related to personal characteristics, attitudes, expectations, and perceived health. In deciding the best decision-making approach to adopt in individual patients, it is of primary importance to measure how the patient perceives and engages in relationships.

Development and testing of the Japanese version of the migraine-specific quality of life instrument

We developed and tested a version of the migraine-specific quality of life (MSQOL) instrument for use in Japan. The MSQOL was translated into Japanese, evaluated by physicians and nurses who has experienced migraine headaches, 'backtranslated', approved by the author of the original version, and tested in 70 out-patients with migraine. There were no ceiling or floor effects. All three subscales were found to be internally consistent: alpha > or = 0.76. The patients' scores were similar to those reported in the user's manual, with the exception of a difference of about 11 points on the Avoidance Behaviors subscale. Some correlations between MSQOL scores and SF-36 scores were statistically significant, although none exceeded 0.52. Linear associations between some measures of symptoms and some MSQOL scales were statistically significant, but those associations were consistent neither for the two kinds of symptom reports (severity and frequency) nor across all MSQOL subscales. Low MSQOL scores in early 1999 correlated with more return visits for medication and with greater amounts of triptan (anti-migraine) medication in 2001 and 2002. Overall, we interpret these results as indicating that, while they cannot be used as substitutes for reports of symptoms, scores on the Japanese version of the MSQOL can be used to assess the impact of migraine headaches on patients' lives.

Health-related quality of life of Japanese patients with overactive bladder treated with extended-release tolterodine or immediate-release oxybutynin: a randomized, placebo-controlled trial

Overactive bladder (OAB) has a significant impact on a patient's health-related quality of life (HRQoL). This study assessed the HRQoL of Japanese OAB patients following 12 weeks' treatment with tolterodine extended release (ER) or oxybutynin. A total of 293 patients with symptoms of OAB were randomized for treatment with tolterodine ER 4 mg once daily (n=114), oxybutynin 3 mg three times daily (n=122) or a placebo (n=57). Treatment efficacy and safety assessments were made over the 12-week period. HRQoL was assessed using the King's Health Questionnaire (KHQ). Patients receiving tolterodine ER or oxybutynin showed a significant (P<0.05) improvement in the Incontinence Impact, Role Limitations and most other KHQ domains compared with the placebo. These changes in HRQoL corresponded with significant (P<0.05) improvements in micturition diary variables for patients receiving tolterodine ER and oxybutynin compared with placebo. Our findings demonstrate that Japanese OAB patients receiving tolterodine ER or oxybutynin experienced overall improvement in their quality of life.

Self report in clinical and epidemiological studies with non-English speakers: the challenge of language and culture

Internationally, there is a drive for equality in health care for ethnic groups. To achieve equality, produce sound policies, and provide appropriately targeted services good quality data are essential. Where data are based upon self report, especially from non-English speakers, there are major barriers to the accumulation of reliable and valid information. When data collection instruments designed for English speakers are simply translated into ethnic minority languages, measurement error can result from inadequate translation procedures, inappropriate content, insensitivity of items, and the failure of researchers to make themselves familiar with cultural norms and beliefs. More attention should be paid to conceptual and cultural factors especially in epidemiological and clinical studies where self report is used to gather data. More interdisciplinary collaboration is necessary as well as a modification of customary methods of data collection and the assumptions behind them. The essence of such modifications entails participatory research with members of the linguistic communities concerned.

Adapting quality of life instruments

Due to the international nature of many clinical studies and trials it is often necessary to produce several language versions of specific measures. While it is generally acknowledged that it is necessary to produce versions that are conceptually equivalent, the best method of achieving this is more controversial. It is commonly stated that there is a gold-standard method, which involves forward and backward translation. However, no evidence has been presented to support this view. This paper argues that the "gold-standard" method is difficult to support and describes an alternative method involving dual translation panels that has been used in the production of all adaptations of needs-based quality of life instruments.

Requirements for quality of life instruments in clinical research

The ability to produce high quality instruments for the assessment of quality of life has advanced considerably in recent years. As the science progresses it has become clear that certain standards must be met if outcome measures are to be capable of providing useful, reliable, and valid information within the context of clinical studies and trials. This paper specifies what these standards are with particular reference to theoretical basis, practicality, acceptability to respondents, unidimensionality, scaling and psychometric properties, and cultural validity and equivalence. The paper also indicates how failure to achieve such standards results in measures that are inaccurate and insensitive to true changes in outcome.

[The Spanish version of the German health-related quality of life questionnaire for children and adolescents: the Kindl]

OBJECTIVES

To obtain a Spanish version of the Kindl semantically and culturally equivalent to the original German version and to test its psychometric properties.

MATERIAL AND METHODS

The methodology used in the adaptation process was based on the forward-backward translation method. To assess the psychometric properties of the Spanish Kindl, the pilot test of the project "Screening for and promotion of HRQL in children and adolescents: a European Public Health perspective (Kidscreen)" it was include in. A classroom was selected for each educational level (8-16 years old) from three schools in Gerona and Barcelona. The Spanish Kindl was administered twice, one week apart. Internal consistency was assessed by computing Cronbach alpha and test-retest stability was assessed using intraclass correlation coefficients (ICC). Analysis of variance was performed according to age, sex, type of school, and self-perceived health status.

RESULTS

Half of the items (12/24) required minor changes during the adaptation process. The response rate was 91 % (n = 447). Internal consistency was acceptable for most domains (alpha range = 0.40-0.88), as was test-retest stability (ICC range = 0.52-0.80). Girls and older teenagers scored worse in most domains (p < 0.01). No differences were found by type of school.

CONCLUSIONS

The Spanish version of the Kindl showed adequate reliability and validity coefficients and represents a new HRQL instrument that can be applied in pediatric clinical practice and public health.

[Measuring health-related quality of life in children and adolescents: preliminary validation and reliability of the Spanish version of the KINDL questionnaire]

OBJECTIVES

To obtain a first Spanish version of the KINDL questionnaire idiomatic and culturally equivalent to the German original version, and then to evaluate its psychometric properties in a sample of healthy children/adolescents 8-16 years old, and their parents.

DESIGN

Cross-sectional study.

SETTING

2 public schools of Asturias of similar sociodemographic conditions.

PARTICIPANTS

243 children 8-16 year-old, and 153 parents were investigated.

MAIN MEASUREMENTS

HRQoL evaluated through the generic questionnaire KINDL. An external assessment through the parents was made as well. The psychometric properties of the Spanish version of the questionnaire were investigated and results on HRQoL are presented for different ages and gender in the Spanish sample.

RESULTS

6 items (6/24) needed successive translations and conceptual discussion during the phase of idiomatic adaptation. The factorial analysis confirmed the validity of construction of the instrument for most scales. The internal consistency, measured by alpha Cronbach coefficent, was good for the total of the questionnaire (>0.70) and acceptable in most of the scales (>0.50). Only the school scale for adolescents shows very poor reliability. Females and children with higher age scored lower in most of the investigated dimensions (P<.01).

CONCLUSIONS

The first Spanish version of the Kindl showed acceptable reliability and validity. In spite of the punctual inadequacies found in this first step of the investigation, the results constitute an important starting point to work further on the KINDL as an HRQoL instrument--in Spanish language--to measure subjective well-being in children.

DLQI scores in vitiligo: reliability and validity of the Persian version

Background

The objective of this study was to translate and to test the reliability and validity of the 10-item Dermatology Life Quality Index (DLQI) questionnaire in Iranian patients with vitiligo.

Methods

Using a standard "forward-backward" translation procedure, the English language version of the questionnaire was translated into Persian (the Iranian official language) by two bilinguals. Seventy patients with vitiligo attending the Department of Dermatology, Saadi Hospital, Shiraz, Iran, were enrolled in this study.

The reliability and internal consistency of the questionnaire were assessed by Cronbach's alpha coefficient and Spearman's correlation, respectively. Validity was performed using convergent validity.

Results

In all, seventy people entered into the study. The mean age of respondents was 28.3 (SD = 11.09) years. Scores on the DLQI ranged from 0 to 24 (mean ± SD, 7.05 ± 5.13). Reliability analysis showed satisfactory result (Cronbach's α coefficient = 0.77). There were no statistically significant differences between daily activity (DA) and personal relationship (PR) scale mean scores in generalized versus focal-segmental involvement in sufferers (P = 0.056, P = 0.053, respectively). There were also strong differences between the mean scores of the PR (personal relationship) scale with the involvement of covered only and covered/uncovered areas (P= 0.016) that was statistically significant in the second group.

Conclusions

The study findings showed that the Persian version of the DLQI questionnaire has a good structural characteristic and is a reliable and valid instrument that can be used for measuring the effects of vitiligo on quality of life.

The Spanish version of the SRS-22 patient questionnaire for idiopathic scoliosis: transcultural adaptation and reliability analysis

STUDY DESIGN

Validation of the transcultural adaptation of a questionnaire for measuring health-related quality of life.

OBJECTIVES

To translate and culturally adapt the SRS-22 questionnaire to Spanish. To determine the metric qualities (internal consistency and test-retest reproducibility) of this questionnaire.

SUMMARY OF BACKGROUND DATA

The SRS-22 Patient Questionnaire has proven to be a valid instrument for clinical assessment of patients with idiopathic scoliosis. The widespread use of the SRS-22 in non-English-speaking countries requires its transcultural adaptation.

METHODS

Transcultural adaptation of the SRS-22 was carried out according to the International Quality of Life Assessment Project guidelines and included two translations and two back-translations of the material. A committee of experts decided on the final version. The questionnaire was administered to 175 individuals (152 women and 23 men) with idiopathic scoliosis. The mean age of the participants at the time they received the questionnaire was 18.9 years, thoracic curve magnitude was 28.8 degrees, and lumbar curve magnitude was 28.1 degrees. At this time, 85 patients had been treated surgically, 45 had been treated with orthesis, and 45 were under observation. A subgroup of 30 patients completed the questionnaire a second time 1 week later. Internal consistency was determined with Cronbach's alpha coefficient and test-retest reliability with the intraclass correlation coefficient.

RESULTS

The overall alpha coefficient of the questionnaire was 0.89. Coefficients for individual domains were as follows: function/activity, 0.67; pain, 0.81; mental health, 0.83; self-image, 0.73; and satisfaction, 0.78. The questionnaire as a whole had an intraclass correlation coefficient of 0.96. Intraclass correlation coefficients for individual domains were as follows: pain, 0.93; function, 0.82; self-image, 0.94; mental health, 0.94; and satisfaction, 0.98.

CONCLUSIONS

The Spanish version of the SRS-22 Patient Questionnaire demonstrated adequate internal consistency for the majority of domains and excellent reproducibility. These results suggest that the process of adaptation has produced an instrument that is apparently equivalent to the original and suitable for clinical research.

Quality of life among people living with HIV/AIDS in northern Thailand: MOS-HIV Health Survey

OBJECTIVES

Translation and psychometric evaluation of a Thai version of the Medical Outcomes Study HIV Health Survey (MOS-HIV) in Thailand.

METHODS

A cross-sectional survey in Chiang Mai province, northern Thailand, with data collected in face-to-face interviews using a structured questionnaire designed to measure 10 scales of quality of life (QOL). We recruited 200 people with HIV/AIDS attending self-help groups in the municipal area. Standard guidelines were followed for questionnaire translation and psychometric evaluations.

RESULTS

Item-level internal consistency and discriminant validity were reasonably established. Success rates were 93.8 and 97.4%, respectively. Scale-level internal consistency reliability of multi-item scales was satisfactory, ranging from 0.74 to 0.88, with all exceeding inter-scale correlations. Principal components analysis of item and scale scores identified two hypothesized dimensions of the MOS-HIV. The mental health component was strongly loaded by health distress, mental health, vitality and cognitive function scales, and physical health by role, physical and social functions, and pain scales. Respondents manifesting symptoms or reporting worsening health status scored significantly lower on all scales.

CONCLUSIONS

These preliminary studies have shown the Thai version of the MOS-HIV to have psychometric properties comparable with those reported in previous surveys. Further testing and modification should make it useful as an HIV-specific QOL measure in Thailand.

Reaching beyond the white middle classes

Apparently simple questions can easily be misunderstood or cause offence in disadvantaged groups. But such problems can be avoided by careful design, piloting, and administration

Translation, adaptation and validation of the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) for an Arab population: the Sfax modified WOMAC

OBJECTIVE

To translate into Arabic and validate the Western Ontario and McMaster Universities (WOMAC) index.

METHOD

Arabic translation was obtained with use of the forward and backward translation method. Adaptations were made after a pilot study. Patients with symptomatic knee OA fulfilling the revised criteria of the American College of Rheumatology were included. Impairment outcome measures (pain as measured on a visual analog scale, the maximum distance walked, Kellgren's radiological score), Lequesne index score and Beck depression scale score were recorded. Each item was analyzed. Test-retest reliability was assessed with use of the intra-class correlation coefficient (ICC) and the Bland and Altman method. Construct validity was investigated with use of Spearman's rank correlation coefficient, and a factor analysis was performed.

RESULTS

One hundred and three patients were included in the study. Eight questions of the WOMAC physical function subscale (PF) had insufficient psychometric properties and were excluded. Although test-retest reliability of the questionnaire was good (0.84, 0.84, and 0.92 for pain, stiffness, and modified PF subscales respectively), construct validity could not be demonstrated. Factor analysis of the modified form of the WOMAC extracted four factors, which differed from the a priori triple stratification. However, factor analysis of the modified PF subscales extracted two factors, which accounted for 68.4% of the total variance and could be clinically characterized (disability during activities requiring knee flexion within the first 90 degrees and activities requiring knee flexion over more than 90 degrees ).

CONCLUSION

We translated and adapted the WOMAC index into Arabic to suit Tunisian people. The translated questionnaire is reliable but not valid in its original form. We propose the use of a modified version of PF subscale of the WOMAC, although the psychometric properties of this instrument must be examined in a larger population.

Use of health-related quality of life in prescribing research. Part 2: methodological considerations for the assessment of health-related quality of life in clinical trials

This article aims to address key methodological issues that should be considered when assessing health-related quality of life (HRQoL) in a clinical trial. These include justification for the selection of HRQoL as a primary or secondary outcome and choice of an appropriate instrument to assess HRQoL, which meets basic psychometric properties. In addition we consider ways to minimize bias within the trial through optimization of compliance and timing of assessments.

[Validation of the Spanish version of the Modified Stanford Health Assessment Questionnaire (MSHAQ), an instrument to measure people's satisfaction at their ability to perform normal day-to-day activities]

OBJECTIVES

To design a Spanish version of the Modified Stanford Health Assessment Questionnaire (MSHAQ), and to evaluate its reliability, internal consistency and validity of construction.

DESIGN

Adaptation using the translation and back-translation method, which focused on ensuring the conceptual equivalence of each item. For the validation study, a cross-sectional study was conducted.Participants. 52 people over 65 being monitored for a chronic clinical condition.

MAIN MEASUREMENTS

As well as anamnesis and the Barthel index, subjects were asked to answer the Spanish version of the MSHAQ on the day of their visit and three days afterwards to evaluate test-retest reliability.

RESULTS

A sample of 52 people, 23 men and 29 women, with a mean age of 74.2 (SD, 5.8) was examined. Study of test-retest reliability showed an intra-class correlation coefficient (ICC) of 0.89, 0.82, 0.88 and 0.51 for Tables A (capacity), B (satisfaction), C (need for help), and D (change in the last 6 months) of the MSHAQ. These four sub-scales were internally consistent, with Crombach's alpha of 0.83, 0.76, 0.61, and 0.82, respectively. There was a statistically significant correlation between all the tables in the questionnaire and between these and Barthel's index.

CONCLUSIONS

It can be concluded that the Spanish version of the MSHAQ is a valid and reliable measuring instrument, which enables studies performed in various countries to be compared.

Public Health Surveillance of Low-Frequency Populations

Public health agencies often require data that address the needs of special populations, such as minority groups. Sources of surveillance data often contain insufficient numbers of subjects to fully inform health agencies. In this review, we address the problems of and potential approaches for situations with insufficient surveillance data. We use the examples of race and ethnic minority groups throughout our discussion. However, many of the broad issues are applicable to other special groups with low frequency or who are especially hard to reach. Our recommendations are based, in part, on a symposium held in Missouri with the collaboration of state health agency, community, and academic research participants. We review problems in using existing data and collecting new data, especially from nonprobability samples. We also describe fieldwork issues for reaching and collecting information from special populations. Decisions among methods and solutions may require seeking additional resources for surveillance.

Health and health care utilisation among asylum seekers and refugees in the Netherlands: design of a study

Background

This article discusses the design of a study on the prevalence of health problems (both physical and mental) and the utilisation of health care services among asylum seekers and refugees in the Netherlands, including factors that may be related to their health and their utilisation of these services.

Methods/Design

The study will include random samples of adult asylum seekers and refugees from Afghanistan, Iran and Somali (total planned sample of 600), as these are among the largest groups within the reception centres and municipalities in the Netherlands.

The questionnaire that will be used will include questions on physical health (chronic and acute diseases and somatization), mental health (Hopkins Symptoms Checklist-25 and Harvard Trauma Questionnaire), utilisation of health care services, pre- and post-migratory traumatic experiences, life-style, acculturation, social support and socio-demographic background. The questionnaire has gone through a translation process (translation and back-translation, several checks and a pilot-study) and cross-cultural adaptation. Respondents will be interviewed by bilingual and bicultural interviewers who will be specifically trained for this purpose.

This article discusses the selection of the study population, the chosen outcome measures, the translation and cross-cultural adaptation of the measurement instrument, the training of the interviewers and the practical execution of the study. The information provided may be useful for other researchers in this relatively new field of epidemiological research among various groups of asylum seekers and refugees.

Development of a health-related quality of life measure for boys with haemophilia: the Canadian Haemophilia Outcomes - Kids Life Assessment Tool (CHO-KLAT)

Several measures of quality of life (QoL) are available for children with haemophilia. However, most are not disease-specific and few focus on children's perspectives. The purpose of this study was to develop a psychometrically sound measure of QoL that included the perspectives of boys with haemophilia. A list of potential items was developed from the literature, other measures, and input from five discussion sessions with adults with haemophilia, children with haemophilia and their parents and haemophilia nurses. The list was augmented with items generated by three focus groups with children and three focus groups with parents. These groups also prioritized items and recommended a domain structure. Supplemental information was gathered by surveying haematologists. Data from all sources were analysed to reduce the number of items using a two-step approach, based on rules that weighted the children's priorities most heavily. The remaining items were compiled into a questionnaire that was pilot tested with 10 children and their parents. The total item pool contained 228 potential items. Of these, 33 were removed based on three focus groups and survey responses, 72 were removed after the completion of all focus groups and 46 were removed due to redundancy. This resulted in a 77-item version of the CHO-KLAT. Pilot testing identified the need to subdivide two items, resulting in a 79-item CHO-KLAT. The CHO-KLAT is a promising disease-specific measure of QoL that reflects children's unique perspectives. This child-centric focus distinguishes the CHO-KLAT from alternative measures of QoL. Further research will assess the measurement properties of the CHO-KLAT.

Translating the Short-Form Headache Impact Test (HIT-6) in 27 countries: methodological and conceptual issues

The process of translating the Short-Form Headache Impact Test (HIT-6) in 27 countries and the comparability of the content of the translations is discussed. HIT-6 translations were developed using a standard forward-backward translation process, including a cognitive debriefing step and international harmonization of the translations. Prior to translating the HIT-6, modifications were made to the English-language source form, to improve translation equivalence. In general, the HIT-6 was not difficult to translate. The most difficult items included colloquial expressions such as 'fed up' and words whose intended meaning changed in translation such as 'school' or 'lie down.' Subjects generally found the HIT-6 translations to be clear and relevant. The translation process resulted in questionnaires that are both culturally appropriate and comparable in content.

Evaluation of quality of life in a clinical trial with nonrandom dropout: the effect of epoetin alfa in anemic cancer patients

Quality of life (QOL) endpoints from a randomized, placebo-controlled trial of anemic cancer patients treated with nonplatinum-containing chemotherapy who received epoetin alfa or placebo were subjected to a sensitivity analysis. Three QOL instruments were used: the Functional Assessment of Cancer Therapy-Anemia (FACT-An), the Cancer Linear Analog Scale (CLAS), and the Medical Outcomes Study Short Form-36 (SF-36). The seven primary endpoints chosen a priori for analysis were: the Functional Assessment of Cancer Therapy-General (FACT-G) Total, FACT-An fatigue subscale, CLAS energy, CLAS daily activities, CLAS overall QOL, and the SF-36 physical and mental component summary scales. Lower QOL scores were reported for patients who discontinued early, suggesting a nonrandom dropout process. Significant correlations (ranging from 0.37 to 0.77) between individual rates of change and the time to early termination of therapy or death supported this conclusion. Estimates of within-treatment-arm QOL change over time are more conservative with the missing not at random (MNAR) assumption as compared with the more optimistic estimates with the assumption that missing QOL data are missing at random (MAR). However, the between-treatment-arm comparisons were consistent across analyses, demonstrating statistically significant differences in favor of the epoetin alfa arm for four of the seven outcome measures.

A comprehensive strategy for the interpretation of quality-of-life data based on existing methods

OBJECTIVES

Health-related quality of life (HRQL) instruments generally undergo a rigorous development and validation process. In contrast, methods for interpreting HRQL data are varied, and no comprehensive widely applicable procedure exists. Determining whether differences are statistically significant is the most common method, but this yields conclusions that may be difficult to understand in a clinical context or which may be of no practical value. Consequently, there is a need for a comprehensive interpretation strategy that gives results that are meaningful to a variety of audiences, including patients, clinicians, and decision-makers.

METHODS

The review of available interpretation strategies revealed that not all methods are applicable to all questionnaires, and some strategies may be difficult to implement for interpreting trial results. In addition, the issues decision-makers may have when assessing HRQL results have not really been addressed: what is measured and what is the meaning beyond statistical significance?

RESULTS

A comprehensive stepwise strategy, based on the most effective methods available, has been developed to address the key interpretation issues of decision-makers. It is structured around several steps: understanding the content of the questionnaire; evaluating the magnitude of changes and their statistical significance; determining whether results are clinically significant, e.g., whether the observed changes crossed ranges of established threshold for meaningful differences; comparing pre- and post-treatment scores distribution with norms of references; and relating score changes to other outcomes end points such as morbidity, death, compliance, resource utilization, or productivity.

CONCLUSIONS

The proposed strategy should help to structure and successfully address interpretation issues and thus make HRQL results more convincing.

Development and psychometric analysis of the Japanese version of the Nottingham Health Profile: cross-cultural adaptation

OBJECTIVE

To adapt the Nottingham Health Profile (NHP) for Japanese and to describe the results of the assessment of its psychometric properties.

METHODS

Assessments included test-retest reliability over approximately a 2-week interval, internal consistency and construct validity in 133 patients with COPD.

RESULTS

The distribution of scores indicated that most of the NHP sections exhibited a floor effect, although this is greatly reduced with the NHP-Distress scale. The test-retest reliability was above 0.8 for all sections when patients reporting any change in their health status rating were excluded. Cronbach's alpha coefficients reflected the number of items contained in each section. The internal consistency of the emotional reactions section at one timepoint and the physical mobility section at both timepoints were lower than expected to be higher. All sections except the pain section could be used to distinguish patients who reported their health status to be good or fair from those who rated it to be poor or very poor.

CONCLUSION

The adaptation of the NHP for Japanese was successful. Most sections showed reasonable test-retest reliability, indicating that they produced acceptable levels of random measurement error. The internal consistency of the sections was confirmed, although the alpha values of the emotional reactions and physical mobility sections were lower than might be expected for scales of their length. Different sections of the Japanese NHP were shown to have known group validity.

Adaptación de la versión española del Perfil de Salud Infantil (Child Health and Illness Profile-Child Edition, CHIP-CE)

OBJECTIVES

To obtain a Spanish version of the CHIP-CE semantically and culturally equivalent to the original version.

METHOD

The methodology used was based on the forward-backward method. Two translations into Spanish were performed. After the first reconciled version, 44 cognitive interviews were carried out with children aged 6-11 years old, selected from two schools in Barcelona. The interviews were recorded and transcribed. A qualitative content analysis of the textual data was carried out. A panel of experts developed the second reconciled version taking into account the children's comments. A back-translation into English was carried out and was compared with the original version.

RESULTS

Of a total of 45 items induced in the first reconciled version, 21 were considered equivalent, 23 required changes and 1 was considered not equivalent. Comprehension of abstract concepts differed according to age. Older children differentiated among concepts and gave different examples of experiences related to these concepts, while younger children (6 to 7-year olds) provided similar examples for different concepts. The children's comments were used in the reformulation of the items. An illustrative figure reinforced understanding. Children aged 7 or more started to use an adequate recall period and used the response options correctly.

CONCLUSIONS

The Spanish version of the CHIP-CE seems appropriate for children aged 6-11 in Spain. The present study shows that children from the age of 6 years onwards are able to describe the health concepts included in the CHIP-CE.

A six-item short-form survey for measuring headache impact: the HIT-6

BACKGROUND

Migraine and other severe headaches can cause suffering and reduce functioning and productivity. Patients are the best source of information about such impact.

OBJECTIVE

To develop a new short form (HIT-6) for assessing the impact of headaches that has broad content coverage but is brief as well as reliable and valid enough to use in screening and monitoring patients in clinical research and practice.

METHODS

HIT-6 items were selected from an existing item pool of 54 items and from 35 items suggested by clinicians. Items were selected and modified based on content validity, item response theory (IRT) information functions, item internal consistency, distributions of scores, clinical validity, and linguistic analyses. The HIT-6 was evaluated in an Internet-based survey of headache sufferers (n = 1103) who were members of America Online (AOL). After 14 days, 540 participated in a follow-up survey.

RESULTS

HIT-6 covers six content categories represented in widely used surveys of headache impact. Internal consistency, alternate forms, and test-retest reliability estimates of HIT-6 were 0.89, 0.90, and 0.80, respectively. Individual patient score confidence intervals (95%) of app. +/-5 were observed for 88% of all respondents. In tests of validity in discriminating across diagnostic and headache severity groups, relative validity (RV) coefficients of 0.82 and 1.00 were observed for HIT-6, in comparison with the Total Score. Patient-level classifications based in HIT-6 were accurate 88.7% of the time at the recommended cut-off score for a probability of migraine diagnosis. HIT-6 was responsive to self-reported changes in headache impact.

CONCLUSIONS

The IRT model estimated for a 'pool' of items from widely used measures of headache impact was useful in constructing an efficient, reliable, and valid 'static' short form (HIT-6) for use in screening and monitoring patient outcomes.

International use of health status questionnaires in Parkinson's disease: translation is not enough

The present study assessed the linguistic and content validity of the Swedish version of the 39-item Parkinson's disease questionnaire (PDQ-39). The frame question, response alternatives and two of the 39 items yielded substantial linguistic and stylistic problems. Such shortcomings would be expected to influence responses to, and the quality of, the whole questionnaire. Data support content validity of the PDQ-39 as a functional health status questionnaire, although some shortcomings were identified. This preliminary study illustrates the need for documented linguistic validity before new language adaptations of patient-reported outcome measures can be considered suitable for use in clinical trials, research, and practice.

Cultural issues in using the SF-36 Health Survey in Asia: results from Taiwan

BACKGROUND

The feasibility of using the SF-36 in non-Western cultures is important for researchers seeking to understand cultural influences upon health status perceptions. This paper reports on the performance of the Taiwan version of the SF-36, including the implications of cultural influences.

METHODS

A total of 1191 volunteered subjects from the general population answered the translated SF-36 Taiwan version, which was developed following IQOLA project protocols.

RESULTS

Results from tests of scaling assumptions and reliability generally were satisfactory. Convergent validity, as assessed by comparing the SF-36 to a mental health oriented inventory, was acceptable. Results of principal components analysis were similar to US results for many scales. However, differences were seen for the Vitality scale which was a stronger measure of mental health than physical health in Taiwan. Results are compared to those from other Asian studies and the U.S.

CONCLUSION

The results raise important questions regarding cultural influences in international studies of health status assessment. Further research into the conceptualization and components of mental health in Asian countries is warranted.

Translating clinical tools in nursing practice

BACKGROUND

The widespread use of clinical tools in nursing practice reflects their usefulness in guiding patient care, evaluating treatment effectiveness and conducting audit. Cultural awareness and the provision of culturally competent care is a high priority for nurses in the United Kingdom (UK), given patterns of increasing ethnic diversity. However, meeting the individual needs of patients can be difficult when language barriers hinder communication. One way to address these difficulties is to translate existing clinical tools.

AIM

The aim of this paper is to appraise the potential for, and limitations of, translating clinical tools for use in nursing practice.

DISCUSSION

Drawing on a range of studies from the disciplines of health and social science, this review describes and discusses some key considerations relevant to translating clinical tools in nursing. These considerations include the need to ensure cultural equivalence, lack of familiarity with clinical tool formats in some cultures and its impact on responses, and low literacy levels in some populations.

CONCLUSION

Clinical tools provide benefits in identifying patients' problems, guiding patient care, and evaluating treatments and interventions. Translating these tools can help to bridge the language gap that hinders good communication between nurses and patients. Translated clinical tools can be of acceptable cultural equivalence and validity if high quality translation methodologies are employed, together with an awareness of culturally relevant issues when interpreting the information gained from the tools.

Health-related quality of life among dialysis patients on three continents: The Dialysis Outcomes and Practice Patterns Study

BACKGROUND

Assessing health-related quality of life (HRQOL) can provide information on the types and degrees of burdens that afflict patients with chronic medical conditions, including end-stage renal disease (ESRD). Several studies have shown important international differences among ESRD patients treated with hemodialysis, but no studies have compared these patients' HRQOL. Our goal was to document international differences in HRQOL among dialysis patients and to identify possible explanations of those differences.

METHODS

We examined data from the Dialysis Outcomes and Practice Patterns Study (DOPPS), a prospective, observational, international study of hemodialysis patients. We performed a cross-sectional analysis of DOPPS data from the United States, five countries in Europe (France, Germany, Italy, Spain, and the United Kingdom), and Japan. Linear mixed models were used to analyze differences in HRQOL, using the KDQOL-SFTM. Norm-based scores were used to minimize cultural response bias. Linear regression analysis was used to adjust for confounding factors. Other variables included demographic variables, comorbidities, primary cause of ESRD, complications of ESRD and treatment, and socioeconomic status.

RESULTS

In all generic HRQOL subscales, patients on all three continents had much lower scores than their respective population norm values. Patients in the United States had the highest scores on the mental health subscale and the highest mental component summary scores. Japanese patients reported better physical functioning than did patients in the United States or Europe, but they also reported the greatest burden of kidney disease. Overall, these differences remained even after adjusting for possible confounders.

CONCLUSION

On all three continents, ESRD and hemodialysis profoundly affect HRQOL. In the United States, the effects on mental health are smaller than in other countries. Japanese hemodialysis patients perceived that their kidney disease imposes a greater burden, but their physical functioning was significantly higher. Different distributions of socioeconomic factors and major comorbid conditions could explain little of this difference in physical functioning. Other possible factors, such as quality of dialysis and related health care, deserve careful study.

A systematic and critical review of the process of translation and adaptation of generic health-related quality of life measures in Africa, Asia, Eastern Europe, the Middle East, South America

In recent years there has been a worldwide increase in demand for subjective measures of health-related quality of life (HRQL). Researchers have the choice of whether to develop a new measure or whether to adapt an existing measure in another language. This review evaluates the processes used in translating and adapting nine generic HRQL instruments (15D, Dartmouth COOP/WONCA Charts, EuroQol, HUI, NHP, SIP, SF-36, QWB, WHOQOL) for use in Africa, Asia, Eastern Europe, the Middle East, and South America. The review adopts a universalist model of equivalence, outlined by Herdman, Fox-Rushby, and Badia (Qual. Life Res. 7 (1998) 323), to judge the 58 papers reviewed. Research spans 23 countries and is dominated by research in the East Asia and Pacific region and the SF-36. Results are reported for conceptual, item, semantic, operational, measurement and functional equivalence. It is argued that currently there is a misguided pre-occupation with scales rather than the concepts being scaled and too much reliance on unsubstantiated claims of conceptual equivalence. However, researchers using the WHOQOL approach are more likely to establish reliable conclusions concerning the equivalence of their instrument across countries. It is a key conclusion of this review that research practice and translation guidelines still need to change to facilitate more effective and less biased assessments of equivalence of HRQL measures across countries.

Use of differential item functioning analysis to assess the equivalence of translations of a questionnaire

In cross-national comparisons based on questionnaires, accurate translations are necessary to obtain valid results. Differential item functioning (DIF) analysis can be used to test whether translations of items in multi-item scales are equivalent to the original. In data from 10,815 respondents representing 10 European languages we tested for DIF in the nine translations of the EORTC QLQ-C30 emotional function scale when compared to the original English version. We tested for DIF using two different methods in parallel, a contingency table method and logistic regression. The DIF results obtained with the two methods were similar. We found indications of DIF in seven of the nine translations. At least two of the DIF findings seem to reflect linguistic problems in the translation. 'Imperfect' translations can affect conclusions drawn from cross-national comparisons. Given that translations can never be identical to the original we discuss how findings of DIF can be interpreted and discuss the difference between linguistic DIF and DIF caused by confounding, cross-cultural differences, or DIF in other items in the scale. We conclude that testing for DIF is a useful way to validate questionnaire translations.

The Spanish version of the Child Health and Illness Profile-Adolescent Edition (CHIP-AE)

The aim of the study was to obtain a conceptually equivalent Spanish version of the Child Health and Illness Profile-Adolescent Edition (CHIP-AE), and to test its feasibility, reliability and preliminary construct validity. The methodology used for adaptation was forward-back translation, including two focus groups with adolescents and a panel of experts. Reliability and validity were assessed in healthy convenience samples from school settings (n = 417). Three different illness groups (n = 67) were used to examine differences in health status between healthy, acutely ill, chronically ill and mentally ill adolescents. Preliminary construct validity was examined by comparing mean scores for each of the subdomains to determine if they differed in predicted ways according to age, gender and illness group. The majority of items (154 out of 203) were conceptually equivalent to the original version. Some items (46) had to be modified to increase clarity and/or to adapt them for use in Spain and 3 items were considered not applicable. Single construct subdomains achieved alpha coefficients between 0.65 and 0.92, and intraclass correlation coefficients (ICC) between 0.57 and 0.93. The mentally ill group presented the worst scores in most domains. The Spanish CHIP-AE is acceptable for Spanish adolescents and shows adequate metric characteristics, which are similar to those reported in the US version.

Chinese SF-36 Health Survey: translation, cultural adaptation, validation, and normalisation

STUDY OBJECTIVE

To develop a self administered Chinese (mainland) version of the Short-Form Health Survey (SF-36) for use in health related quality of life measurements in China.

DESIGN

A three stage protocol was followed including translation, tests of scaling construction and scoring assumptions, validation, and normalisation.

SETTING

1000 households in 18 communities of Hangzhou.

PARTICIPANTS

1688 respondents recruited by multi-stage mixed sampling.

MAIN RESULTS

The assumption of equal intervals was violated for the vitality and mental health scales. The recoded item values were used to calculate scale scores. The clustering and ordering of item means was the same as that of the source and other two Chinese versions. The items in each scale had similar standard deviations except those in the physical functioning, boduily pain, social functioning scales. The item hypothesised scale correlations were identical for all except the social functioning and vitality scales. Convergent validity and discriminant validity were satisfactory for all except the social functioning scale. Cronbach's alpha coefficients ranged from 0.72 to 0.88 except 0.39 for the social functioning scale and 0.66 for the vitality scale. Two weeks test-retest reliability coefficients ranged from 0.66 to 0.94. Factor analysis identified two principal components explaining 56.3% of the total variance. The Chinese SF-36 could distinguish known groups.

CONCLUSIONS

This study suggested that the Chinese (mainland) version of the SF-36 functioned in the general population of Hangzhou, China quite similarly to the original American population tested. Caution is recommended in the interpretation of the social functioning and vitality scales pending further studies.

The SF-36 questionnaire and its usefulness in population studies: results of the German Health Interview and Examination Survey 1998

OBJECTIVES

To describe the distribution and the relationships of the SF-36 scales in a representative sample of the German population.

METHODS

The German National Health Interview and Examination Survey 1998 comprised 7,124 participants aged 18 to 79 years and included the Short Form 36 Questionnaire (SF-36). The 1998 findings are compared to those of the first normative German SF-36 sample from 1994.

RESULTS

Older people (> or = 65 years) in particular have increased the mean scale values for quality-of-life assessment during the four years. The average of all SF-36 scales increases with the social status of the individual in all age categories. The representative sample shows a more positive subjective assessment of their quality-of-life by East Germans in nearly all scales of SF-36, although they do not have a correspondingly better health status. The intensity of pain and the number of diseases during the preceding year are shown to decrease the life quality scales. Furthermore the General Health scale of SF-36 is correlated with the physicians' consultation.

CONCLUSION

The instrument to assess quality-of-life can generate useful information for a wide variety of variables. However, future health-related quality-of-life measurements in healthy population should be more sensitive and more differentiating than the SF-36 instruments.

Health-related quality of life in gynecological oncology: instruments and psychometric properties

Quality of life is generally recognized as a subjective, multidimensional concept, which places emphasis on the self-perception and subjective experience of the patient compared to the expectation of an individual's current health state. Health-related quality of life, which encompasses the psychological, physical, and social functioning of patients, has evolved over recent decades into an established treatment outcome in cancer clinical trials. Assessing quality of life as a clinical trial outcome enables clinicians to better address concerns of gynecological oncology patients, but selection of appropriate measurement tools is critical. This article reviews the concepts of reliability and validity, and describes three health-related quality of life instruments, their psychometric properties, and their use in gynecological oncology clinical trials and other cancer research.

Multivariate regression analyses of data from a randomised, double-blind, placebo-controlled study confirm quality of life benefit of epoetin alfa in patients receiving non-platinum chemotherapy

Cancer-related anaemia is associated with a wide spectrum of symptoms that can negatively affect quality of life. Because epoetin alfa has demonstrated efficacy in correcting cancer-related anaemia, the impact of this treatment on quality of life was evaluated in a multinational, randomised, double-blind, placebo-controlled trial in 375 anaemic cancer patients receiving non-platinum-based chemotherapy. The cancer-specific measures of quality of life included the general scale (FACT-G Total) and fatigue subscale (FACT-An Fatigue subscale) of the Functional Assessment of Cancer Therapy-Anaemia and the Cancer Linear Analogue Scales measuring energy, ability to do daily activities, and overall quality of life. These measures were also used to examine the relationship between haemoglobin levels and quality of life. Both univariate and multiple linear regression analyses of quality of life data were performed. Results of the univariate analysis have been reported previously. The a priori-planned multiple linear regression analysis, which accounted for the effects of disease progression and several other possibly confounding variables on quality of life, showed a significant advantage for epoetin alfa over placebo for the five scales (all, P<0.05), and confirmed the results of the univariate analysis. For cancer-specific measures, significant correlations were demonstrated between baseline haemoglobin and quality of life (r, range: 0.14-0.26, all P<0.05) and between change in haemoglobin and change in quality of life (r, range: 0.26-0.34, all P<0.01). These findings provide evidence that increasing haemoglobin levels by epoetin alfa administration can significantly improve cancer patients' quality of life.

Psychometric properties of the SF-12 (Hebrew version) in a primary care population in Israel

OBJECTIVE

To evaluate the psychometric properties of the 12-item Medical Outcomes Study (MOS) Short-Form Health Status Survey (SF-12) (Hebrew version) in a large primary care patient sample in Israel.

SUBJECTS

The sample comprised 3631 adult primary care patients who were screened for depression in a longitudinal design.

MEASURES

SF-12 yielding two scores: the Physical Component Summary (PCS-12) and Mental Component Summary (MCS-12). For comparison, the Center for Epidemiological Studies - Depression scale (CES-D), two subscales from the 90-item Hopkins Symptom Scale (SCL-90), Quality of Life Depression Scale (QLDS), World Health Organization Quality of Life Measure - Bref (WHOQoL-Bref), and interviewer-administered Composite International Diagnostic Interview (CIDI) were also administered.

RESULTS

Score distribution was satisfactory, the amount of missing data was minimal and item-to-item correlations were satisfactory. Floor and ceiling effects were minimal in items with more than three response options. A confirmatory factor analysis supported the two-dimensional model of health. Test-retest reliability was good for both summary scales in a nondepressed population and for PCS-12 in the depressed population, but only moderate for MCS-12 in the depressed population. In regard to convergent validity, MCS-12 correlated negatively and significantly with the CES-D, QLDS, and two SCL-90 anxiety subscales, and positively and significantly with four WHOQoL-Bref domains. PCS-12 correlated positively and significantly with the WHOQoL-Bref physical domain. Discriminative validity was established in that both PCS-12 and MCS-12 showed meaningful effect sizes between groups with various degrees of physical and mental health problems. Sensitivity to change was established in that both PCS-12 and MCS-12 change scores were significantly different in subjects who had been depressed but were no longer so, as compared with those who were still depressed at follow-up.

CONCLUSIONS

The SF-12 (Hebrew version) is a reliable and valid measure, particularly in a nondepressed population.

Assessing quality of life of children with chronic health conditions and disabilities: a European approach

Quality of life has been used as a synonym for a subject-centred or individually appraised perspective on health. Despite the increase in quality of life research in adults, quality of life in children is relatively neglected. While generic measures begin to emerge now, methods to assess the quality of life of children with chronic conditions are still in development. The design of such an assessment tool for different age groups and different levels of disabilities is the objective of a European-Union-funded study: the DISABKIDS project. In addition, it addresses the psychosocial determinants of quality of life in children with disabilities. A major aim of the project is to develop and test instruments for children and adolescents with disabilities (as well as for their families) in seven countries, to assess the impact of the chronic health conditions on quality of life and to provide a tool for systematic monitoring of the quality of care given to children with disabilities. Assessment and monitoring will allow identification of unmet health care needs and, it is hoped, ultimately, the fostering of the development of effective intervention strategies.

Instrument translation and evaluation of equivalence and psychometric properties: the Chinese Sense of Coherence Scale

Translating well-established English instruments into target languages other than English and testing cross-cultural validity to prove that the same attributes are being measured in each cultural group or country are required before a multicultural or international study can be conducted and cross-cultural comparisons of study results can be applied. However, rigorous and systematic cross-cultural efforts to test the effectiveness of specific translation methods are rare. This article presents a model of translation processes and empirical validation of the translated instrument through description of the translation of a selected instrument--the Sense of Coherence (SOC) Scale--from English into Chinese. A cyclic process of forward translations, back translations, and expert evaluation of equivalence by bilingual and English speaking experts was conducted to achieve conceptual equivalence between the original and translated instruments. Empirical validation of the Chinese SOC scale data from a group of bilingual Chinese people demonstrated non-identical, but comparable, item and scale means and variances, internal consistency, and relationships to an external criterion. Advantages and difficulties of using multi-rounds, multi-experts, and multi-methods to establish translation equivalence and to validate the translated Chinese SOC scale are discussed.

Validation of the KDQOL-SF: a dialysis-targeted health measure

BACKGROUND

In evaluations of dialysis therapy, an assessment of health-related quality of life (HRQOL) is often important. The aim of this study was to determine the basic psychometric properties, reliability and validity of the short form of the KDQOL i.e. the KDQOL-SF, a dialysis-targeted instrument, and to assess its ability to detect changes over time.

METHODS

In a prospective cohort study (Netherlands Cooperative Study on the Adequacy of Dialysis, NECOSAD), all new adult ESRD patients in 32 different Dutch centers were consecutively enrolled. Demographic, clinical and HRQOL data were obtained 3 and 12 months after the start of chronic dialysis therapy.

RESULTS

The reliability of the KDQOL-SF was supported by test results that were above the recommended minimal values. Validity of KDQOL-SF was confirmed by the hypothesized positive correlations of the overall health rating and renal function, and by the negative correlations between the number of comorbidities and dialysis dose. Moreover, dialysis-targeted dimensions were more sensitive in detecting relevant differences pertaining to kidney diseases than generic dimensions. The KDQOL-SF was able to detect clinical changes over time.

CONCLUSIONS

The psychometric properties of the KDQOL-SF were good, and the different dialysis-targeted dimensions were informative with a high reliability and validity. These results support the application of the KDQOL-SF in studies evaluating dialysis therapy.

French translation and validation of 3 functional disability scales for neck pain

OBJECTIVE

To translate and assess the reliability and the construct validity of 3 functional disability scales for neck pain.

DESIGN

Reliability and validity study.

SETTING

Tertiary care teaching hospital and outpatient clinic.

PARTICIPANTS

One hundred one patients (mean age, 49 y).

INTERVENTION

French translations were obtained by using the "translation-backward translation" method. Adaptations were made after a pilot study.

MAIN OUTCOME MEASURES

Impairment outcome measures (visual analog scale [VAS] pain, neck range of motion, morning stiffness, score of neck sensitivity, radiologic score of Kellgren) and patients' perceived handicap (VAS) were recorded at the baseline visit. Three functional disability scales (Neck Disability Index [NDI], Neck Pain and Disability Scale [NPDS], Northwick Park Neck Pain Questionnaire [NPQ]) were recorded twice, at baseline visit and 24 hours later. Reliability was assessed by using the intraclass correlation coefficient (ICC) and the Bland and Altman method. Construct (convergent and divergent) validity was investigated by using the Spearman rank correlation coefficient and a factor analysis was performed.

RESULTS

Test-retest was excellent for the NPDS and NDI (ICC =.91,.93, respectively) and good for the NPQ (ICC =.84). The Bland and Altman method showed no systematic trend. Expected convergent and divergent validity were observed only for the NPDS; 3 main factors were extracted by factor analysis and explained 78% of the cumulative variance.

CONCLUSION

The 3 translated scales are valid, but the NPDS seems to have the best construct validity.

Pain measurement tools and methods in clinical research in palliative care: recommendations of an Expert Working Group of the European Association of Palliative Care

An Expert Working Group was convened under the auspices of the Steering Committee of the Research Network of the European Association of Palliative Care to review the status of the use of pain measurement tools (PMTs) in palliative care research conducted in a multilingual-multicenter setting. Based on a literature review and on the experts' opinion, the present work recommends that standardized methods should be applied for the use of PMTs in research in palliative care. Visual analogue scales, numerical rating scales, and verbal rating scales are considered valid to assess pain intensity in clinical trials and in other types of studies. Among the multidimensional questionnaires designed to assess pain, the McGill Pain Questionnaire and Brief Pain Inventory are valid in many multilingual versions. Specific recommendations for PMT use and administration, depending on the study type and aim, are reviewed. Special population requirements specific of clinical situations encountered in palliative care (elderly, terminal, cognitively impaired patients, pediatric patients) are also considered.

Quality of life in children and adolescents: a European public health perspective

OBJECTIVES

The measurement of health-related quality of life (HRQOL) is increasingly important as a means of monitoring population health status over time, of detecting sub-groups within the general population with poor HRQOL, and of assessing the impact of public health interventions within a given population. At present, no standardised instrument exists which can be applied with equal relevance in pediatric populations in different European populations. The collaborative European KIDSCREEN project aims to develop a standardised screening instrument for children's quality of life which will be used in representative national and European health surveys. Participants of the project are centres from Austria, France, Germany, Netherlands, Spain, Switzerland, and United Kingdom. By including the instrument in health services research and health reporting, it also aims at identifying children at risk in terms of their subjective health, thereby allowing the possibility of early intervention.

METHODS

Instrument development will be based on constructing a psychometrically sound HRQOL instrument taking into account the existing state of the art. Development will centre on literature searches, expert consultation (Delphi Methods) and focus groups with children and adolescents (8-17 years). According to international guidelines, items will be translated into the languages of the seven participating countries for a pilot test with 2,100 children and their parents in Europe. The final instrument will be used in representative mail and telephone surveys of HRQOL in 1,800 children and their parents per country (total n = 25,200) and normative data will be produced. The potential for implementing the measurement tool in health services and health reporting will also be evaluated in several different research and public health settings. The final analysis will involve national and cross cultural-analysis of the instrument.

RESULTS

The international, collaborative nature of the KIDSCREEN project means it is likely to provide many challenges in terms of producing an instrument which is conceptually and linguistically appropriate for use in many different countries, but it will also provide the opportunity to develop, test and implement the first truly cross-national HRQOL instrument developed for use in children and adolescents. This will help to contribute to a better understanding of perceived health in children and adolescents and to identify populations at risk.

Comparison of German language versions of the QWB-SA and SF-36 evaluating outcomes for patients with prostate disease

BACKGROUND

The quality of well-being scale (QWB) and the Medical Outcome Study 36-item short form (SF-36) are alternative methods for measuring general health outcomes. Few studies compare these approaches against one another and no studies have compared German language versions.

METHOD

A German language version of the self-administered quality of well-being scale (QWB-SA) was developed using forward and back translation methods. The German QWB-SA and a German language version of the SF-36 were administered to clinical population groups with current diagnoses of prostate cancer, benign hyperplasia of the prostate, colon cancer, and rectal cancer. Data were obtained from four German clinics. In addition to the quality of life measures, data on cancer stage and disease state were obtained.

RESULTS

The QWB-SA and SF-36 were highly correlated. The QWB-SA was systematically related to disease state. Those with no symptomatic evidence had the highest scores followed by those who were stable with no metastatic disease and those with metastatic progression. Similar patterns were found for most SF-36 scales although the SF-36 failed to discriminate between those with no evidence of disease and those with stable disease without metastasis.

CONCLUSIONS

Both the QWB-SA and SF-36 perform as expected using German language translations. Although both measures differentiate patients with metastasis from those without symptoms, the QWB-SA better differentiated those with no evidence of disease from those with stable disease without metastasis.

Translation, cultural adaptation, and initial reliability and multitrait testing of the Kidney Disease Quality of Life instrument for use in Japan

BACKGROUND

The Kidney Disease Quality of Life instrument (KDQOL) consists of 79 items: 36 asking about health-related quality of life (HRQOL) in general (the Medical Outcomes Study SF-36) and 43 asking about QOL as it is affected by kidney disease and by dialysis.

AIM

Translation, cultural adaptation and initial reliability and multitrait testing of the KDQOL for use in Japan.

METHODS

Translation and cultural adaptation began with two translations into Japanese, two backtranslations into English, and discussions among the translators, the project coordinators in Japan, and the developers of the original (US-English) version. Focus-group discussions and field testing were followed by analyses of test-retest reliability, internal consistency, and convergent and discriminant construct validity.

RESULTS

All eight of the SF-36 scales met the criterion for internal consistency (Cronbach's alpha ranged from 0.73 to 0.92) and were reproducible (intraclass correlations between test and retest scores ranged from 0.60 to 0.82). Of the 10 kidney-disease-targeted scales, only two had alpha coefficients of less than 0.70: 'sleep' (0.61) and 'quality of social interaction' (0.35). One item on the 'quality of social interaction' scale had a very weak correlation with the remainder of that scale (r = 0.10). Eliminating that item from scoring increased the alpha coefficient of the scale from 0.35 to 0.64. All three items on the 'quality of social interaction' scale had very strong correlations with other scales.

CONCLUSIONS

First, in Japanese patients receiving dialysis the SF-36 scales are internally consistent and their scores are reproducible. Second, with the possible exception of the 'quality of social interaction' scale, the Japanese version of the KDQOL, can provide psychometrically sound kidney-disease-targeted data on quality of life in such patients.

The RAND-36 measure of health-related quality of life

The RAND-36 is perhaps the most widely used health-related quality of life (HRQoL) survey instrument in the world today. It is comprised of 36 items that assess eight health concepts: physical functioning, role limitations caused by physical health problems, role limitations caused by emotional problems, social functioning, emotional well-being, energy/fatigue, pain, and general health perceptions. Physical and mental health summary scores are also derived from the eight RAND-36 scales. This paper provides example applications of the RAND-36 cross-sectionally and longitudinally, provides information on what a clinically important difference is for the RAND-36 scales, and provides guidance for summarizing the RAND-36 in a single number. The paper also discusses the availability of the RAND-36 in multiple languages and summarizes changes that are incorporated in the latest version of the survey.