Reconsidering the psychometrics of quality of life assessment in light of response shift and appraisal

Factorial structure of the locomotor disability scale in a sample of adults with mobility impairments in Bangladesh

Background

Disability does not only depend on individuals’ health conditions but also the contextual factors in which individuals live. Therefore, disability measurement scales need to be developed or adapted to the context. Bangladesh lacks any locally developed or validated scales to measure disabilities in adults with mobility impairment. We developed a new Locomotor Disability Scale (LDS) in a previous qualitative study. The present study developed a shorter version of the scale and explored its factorial structure.

Methods

We administered the LDS to 316 adults with mobility impairments, selected from outpatient and community-based settings of a rehabilitation centre in Bangladesh. We did exploratory factor analysis (EFA) to determine a shorter version of the LDS and explore its factorial structure.

Results

We retained 19 items from the original LDS following evaluation of response rate, floor/ceiling effects, inter-item correlations, and factor loadings in EFA. The Eigenvalues greater than one rule and the Scree test suggested a two-factor model of measuring locomotor disability (LD) in adults with mobility impairment. These two factors are ‘mobility activity limitations’ and ‘functional activity limitations’. We named the higher order factor as ‘locomotor disability’. This two-factor model explained over 68% of the total variance among the LD indicators. The reproduced correlation matrix indicated a good model fit with 14% non-redundant residuals with absolute values > 0.05. However, the Chi-square test indicated poor model fit (p < .001). The Bartlett’s test of Sphericity confirmed patterned relationships amongst the LD indicators (p < .001). The Kaiser-Meyer-Olkin Measure (KMO) of sampling adequacy was .94 and the individual diagonal elements in the anti-correlation matrix were > .91.

Among the retained 19 items, there was no correlation coefficient > .9 or a large number of correlation coefficients < .3. The communalities were high: between .495 and .882 with a mean of 0.684. As an evidence of convergent validity, we had all loadings above .5, except one. As an evidence of discriminant validity, we had no strong (> .3) cross loadings and the correlation between the two factors was .657. The ‘mobility activity limitations’ and ‘functional activity limitations’ sub-scales demonstrated excellent internal consistency (Cronbach’s alpha were .954 and .937, respectively).

Conclusions

The 19-item LDS was found to be a reliable and valid scale to measure the latent constructs mobility activity limitations and functional activity limitations among adults with mobility impairments in outpatient and community-based settings in Bangladesh.

A systematic review of outcome measures utilised to assess self-management in clinical trials in patients with chronic pain

OBJECTIVES

The aim of this review was to identify, appraise and synthesise the outcome measures used to assess self-management in patients with chronic pain.

METHODS

Medline, Embase, CINAHL, PsycINFO, the Cochrane Library and Google Scholar were searched to identify quantitative measures used within randomised or non-randomised clinical trials to assess self-management in adults (≥18 years) with chronic pain.

RESULTS

25 RCTs published between 1998 and 2016 were included in this review. Studies included patients with chronic pain, hip/knee osteoarthritis, rheumatoid arthritis, chronic low back pain, fibromyalgia and chronic fatigue syndrome. Included studies utilised 14 different measures assessing a variety of constructs including self-efficacy (n = 19), coping (n = 4), empowerment (n = 2), pain attitude and management (n = 3), self-care (n = 1), role behaviour (n = 1) and multiple constructs of self-management (n = 1). The Chronic Pain Coping Inventory (CPCI) and Health Education Impact Questionnaire (heiQ) cover different self-management related constructs across the physical, mental and social health domains.

CONCLUSION

The review identified 14 measures used as proxy measure to assess self-management in patients with chronic pain. These measures have good content and construct validity, and internal consistency. However additional research is required to develop their reliability, responsiveness and interpretability.

PRACTICE IMPLICATIONS

Multi-constructs measures (CPCI, heiQ) are suitable for assessing self-management.

Impact of reconceptualization response shift on rating of quality of life over time among people with advanced cancer

BACKGROUND

People with cancer may experience change in what constitutes quality of life (QOL) over time as a result of the cancer progression (true change) or adaptation to the experience, considered as a response shift phenomenon. As individualized measures are ideally suited to explore response shift, this study aimed to estimate the extent to which reconceptualization response shift occurred over time in a cancer population and the impact of this response shift on estimates of change on QOL measures.

METHODS

Ninety-seven people with advanced cancer completed the study measures including the Patient-Generated Index (PGI) at diagnosis (T0) and 1 year later (T1). The response shift indicator was the change in the number of areas nominated (range - 4 to + 3). Multivariate linear regression was used to estimate the effect of changing areas on change in the PGI score, single indicators of global QOL, and the EQ-5D_index adjusted for age and sex.

RESULTS

Approximately 72% of people in this sample either added or dropped areas over time. People who dropped more than two areas had higher PGI scores at T1 than T0 while people who added areas showed low PGI score.

CONCLUSION

The results are consistent with the PGI framework as areas nominated tend to focus on negative aspects of QOL.

Quality of Life and Adaptation in People With Spinal Cord Injury: Response Shift Effects From 1 to 5 Years Postinjury

OBJECTIVE

To investigate response shift effects in spinal cord injury (SCI) over 5 years postinjury.

DESIGN

Prospective cohort study observed at 1, 2, and 5 years post-SCI.

SETTING

Specialized SCI centers.

PARTICIPANTS

Sample included 1125, 760, and 219 participants at 1, 2, and 5 years post-SCI (N = 2104). The study sample was 79% men; 39% were motor/sensory complete (mean age, 44.6±18.3y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patient-reported outcomes included the Medical Outcomes Study 36-Item Short-Form Health Survey version 2 and the Life Satisfaction-11 Questionnaire. Participant latent variable scores were adjusted for (1) potential attrition bias and (2) propensity scores reflecting risk of worse outcomes. The Oort structural equation modeling approach for detecting and accounting for response shift effects was used to test the hypothesis that people with SCI would undergo response shifts over follow-up.

RESULTS

The study data comprised the time after FIM scores, an objective measure of motor and cognitive function, had improved and stabilized. Three latent variables (Physical, Mental, and Symptoms) were modeled over time. The response shift model indicated uniform recalibration and reconceptualization response shift effects over time. When adjusted for these response shift effects, Physical showed small true change improvements at 2- and 5-year follow-up, despite FIM stability.

CONCLUSIONS

We detected recalibration and reconceptualization response shift effects in 1- to 5-year follow-up of people with SCI. Despite stable motor and cognitive function, people with SCI are adapting to their condition. This adaptation reflects a progressive disconnection between symptoms and physical or mental health, and a real improvement in the Physical latent variable.

Social Role Participation and Satisfaction With Life: A Study Among Patients With Ankylosing Spondylitis and Population Controls

OBJECTIVE

Participation in society of persons with chronic diseases receives increasing attention. However, little is known about which components of participation are most relevant to life satisfaction. This study examines the association between several aspects of social role participation and satisfaction with life (SWL) in patients with ankylosing spondylitis (AS) compared to population controls.

METHODS

In a cross-sectional study, participants completed the Social Role Participation Questionnaire (SRPQ) and SWL scale. The SRPQ assesses several dimensions of participation (importance, satisfaction with performance, and satisfaction with time and physical difficulty) in 11 roles representing 3 domains (interpersonal relations, leisure, and work). For individuals with AS and controls, the association between role domains and SWL was examined using linear regression for each participation dimension separately, in the total and the employed population, adjusting for age, sex, education, and income.

RESULTS

A total of 246 AS patients (mean ± SD age 51 ± 12 years, 62% males, mean ± SD disease duration 17 ± 12 years) and 510 controls (mean ± SD age 42 ± 15 years, 70% males) were included. AS patients were more frequently (extremely) dissatisfied with life (17.9% versus 8.6%; P < 0.05). In the total and the employed population, less physical difficulty and higher satisfaction with interpersonal relations and leisure were associated with higher SWL, and this was somewhat stronger in patients than in controls (P < 0.1). In employed controls, but not in employed patients, satisfaction with work was independently associated with SWL.

CONCLUSION

These findings highlight the importance of supporting persons with AS in ameliorating social role participation, particularly in areas like close relationships and leisure activities, which are typically ignored when treating AS.

Developing the content of a locomotor disability scale for adults in Bangladesh: a qualitative study

Background

Bangladesh has an estimated 17 million adults with disabilities. A significant proportion of them are believed to have locomotor disabilities. There are over 300 non-governmental organizations providing different types of rehabilitation services to them. However, there is no locally developed and validated locomotor disability measurement scale in Bangladesh. The purpose of this study was to develop a locomotor disability scale with disability indicators suitable for adults in Bangladesh.

Methods

Semi-structured interviews were conducted with 25 purposively selected adults with locomotor disabilities to generate scale items. At the second stage, cognitive interviews were conducted with 12 purposively selected adults with locomotor disabilities in order to refine the measurement questions and response categories. Data were analysed using the framework technique- identifying, abstracting, charting and matching themes across the interviews.

Results

For a locomotor disability scale, 70 activities (disability indicators) were identified: 37 mobility activities, 9 activities of daily living, 17 work/productivity activities and 7 leisure activities. Cognitive interviews revealed that when asking the respondents to rate their difficulty in performing the activities, instead of just mentioning the activity name, such as taking a bath or shower, a detailed description of the activity and response options were necessary to ensure consistent interpretation of the disability indicators and response options across all respondents.

Conclusions

Identifying suitable disability indicators was the first step in developing a locomotor disability scale for adults in Bangladesh. Interviewing adults with locomotor disabilities in Bangladesh ensured that the locomotor disability scale is of relevance to them and consequently it has excellent content validity. Further research is needed to evaluate the psychometric properties of this scale.

Development of a practical outcome measure to account for individual differences in quality-of-life appraisal: the Brief Appraisal Inventory

BACKGROUND

The present study evaluated the distributional and structural characteristics and explanatory power of the 23-item Brief Appraisal Inventory (BAI), a more practical appraisal measure for use in clinical research and practice.

METHODS

A heterogeneous, online cohort of chronic disease patients and caregivers completed the BAI, along with demographics, comorbidities, PROMIS-10, and the Brief NEO Personality Inventory. Principal components, bivariate, and linear and logistic regression analyses addressed BAI item distributions, structure, and construct validity.

RESULTS

The study sample (n = 592) had a mean age of 43.8 (SD = 18.5), and was 79% female. The BAI items exhibited good distributions, and principal component analysis yielded five composite scores: (1) Health Worries; (2) Interpersonal and Independence concerns; (3) Accomplishing Goals and Problem-Solving; (4) Calm, Peaceful, and Active; (5) Spiritual Growth and Altruism. The construct validity of appraisal factors is supported by their zero-order correlations with demographic, health, personality, and health-related QOL measures. Comparisons of appraisal-correlates among comorbidity-burden subgroups shed light on the mediating role that appraisal may play in adapting to chronic illness. Appraisal moderated the influence of comorbidities on emotional but not physical functioning. The performance of the BAI in explaining unique variance in physical and emotional functioning is comparable to results obtained with earlier measures.

CONCLUSIONS

The BAI provides a practical, short tool for evaluating appraisal in a wide range of assessment situations. Future research might utilize the BAI in longitudinal research aimed at detecting response-shift effects over time, and in clinical settings to improve patient-provider communication about concerns related to health, health care, or QOL.

Resilience to health challenges is related to different ways of thinking: mediators of physical and emotional quality of life in a heterogeneous rare-disease cohort

BACKGROUND

We sought to understand what distinguishes people who confront health challenges but still manage to thrive. This study investigated whether resilience helps to explain the impact of health challenges on quality of life (QOL) outcomes, and how resilience relates to appraisal.

METHODS

A web-based survey of rare-disease panel participants included the Centers for Disease Control Healthy Days Core Module, the PROMIS-10, and comorbidities. The QOL Appraisal Profile-v2 assessed cognitive processes underlying QOL. Resilience was operationalized statistically using residual modeling, and hierarchical regressions tested the mediation hypothesis that resilience accounts for a significant amount of the relationship of appraisal to QOL.

RESULTS

The study sample (n = 3,324; mean age 50; 86% female; 90% White) represented a range of diagnostic codes, with cancer and diseases of the nervous system being the most prevalent health conditions. After adjusting for comorbidities (catalysts), resilience was associated with better physical and emotional functioning, and different appraisal processes were associated with better or worse physical or emotional functioning. After controlling for catalysts, 62% of the association of Physical Functioning and 23% of the association between Emotional Functioning and appraisal were mediated by resilience. Physical and emotional resilience comprised some of the same appraisal processes, but physically resilient people were characterized by more appraisal processes than their emotionally resilient counterparts.

CONCLUSIONS

Resilient people employ different appraisal processes than non-resilient people, and these processes differ for physical and emotional outcomes. Resilience was a stronger mediator of the relationship between physical rather than emotional functioning and appraisal.

Distinguishing appraisal and personality influences on quality of life in chronic illness: introducing the quality-of-life Appraisal Profile version 2

BACKGROUND

Cognitive appraisal of quality of life (QOL) differs across individuals in ways that explain otherwise paradoxical findings, such as similar QOL ratings among individuals in highly divergent health states. Although warranted by a growing body of evidence, routine assessment of appraisal in QOL research has been impeded by measurement challenges. This study describes the QOL Appraisal Profile-version 2 (QOLAPv2), a new measure that addresses these challenges.

METHODS

A heterogeneous, on-line cohort of chronic disease patients and caregivers completed the QOLAPv2, along with demographics, PROMIS10 and Brief NEO Personality Inventory (NEO-PI). Analyses address the psychometric properties and construct validity of this new measure using principal components, bivariate, canonical correlation, and linear regression analyses.

RESULTS

Analysis including 4173 respondents yielded 12 second-order QOLAPv2 principal components. Appraisal components varied with age and disease duration. Appraisals involving "Wellness," "Health," and "Recent Challenges" were correlated with QOL and with NEO-PI scales of "Agreeableness" and "Conscientiousness." Canonical correlation analysis revealed that QOL scales were associated with appraisals involving "Spirituality," "Anticipating Decline," and "Lightness of Being." Appraisal dimensions of "Relationships," "Maintaining Roles," "Independence," "Pursuing Dreams," and "Lightness of Being" were also associated with personality scales. Appraisal measures accounted for significantly more variance in QOL than personality and demographics alone.

CONCLUSIONS

Findings corroborate the Rapkin and Schwartz QOL appraisal theory. QOL appraisal measures correlate as expected with personality scales, and explain more variance in QOL than does personality. The QOLAPv2 can be used across populations to provide insight into patients' concerns, salient experiences, and comparators.

The Health Literacy Questionnaire (HLQ) at the patient-clinician interface: a qualitative study of what patients and clinicians mean by their HLQ scores

BACKGROUND

The Health Literacy Questionnaire (HLQ) has nine scales that each measure an aspect of the multidimensional construct of health literacy. All scales have good psychometric properties. However, it is the interpretations of data within contexts that must be proven valid, not just the psychometric properties of a measurement instrument. The purpose of this study was to establish the extent of concordance and discordance between individual patient and clinician interpretations of HLQ data in the context of complex case management.

METHODS

Sixteen patients with complex needs completed the HLQ and were interviewed to discuss the reasons for their answers. Also, the clinicians of each of these patients completed the HLQ about their patient, and were interviewed to discuss the reasons for their answers. Thematic analysis of HLQ scores and interview data determined the extent of concordance between patient and clinician HLQ responses, and the reasons for discordance.

RESULTS

Highest concordance (80%) between patient and clinician item-response pairs was seen in Scale 1 and highest discordance (56%) was seen in Scale 6. Four themes were identified to explain discordance: 1) Technical or literal meaning of specific words; 2) Patients' changing or evolving circumstances; 3) Different expectations and criteria for assigning HLQ scores; and 4) Different perspectives about a patient's reliance on healthcare providers.

CONCLUSION

This study shows that the HLQ can act as an adjunct to clinical practice to help clinicians understand a patient's health literacy challenges and strengths early in a clinical encounter. Importantly, clinicians can use the HLQ to detect differences between their own perspectives about a patient's health literacy and the patient's perspective, and to initiate discussion to explore this. Provision of training to better detect these differences may assist clinicians to provide improved care. The outcomes of this study contribute to the growing body of international validation evidence about the use of the HLQ in different contexts. More specifically, this study has shown that the HLQ has measurement veracity at the patient and clinician level and may support clinicians to understand patients' health literacy and enable a deeper engagement with healthcare services.

Stability of the alcohol use disorders identification test in practical service settings

Objective

The purpose of the present study is to explore the stability of the Alcohol Use Disorders Identification Test (AUDIT) in a clinical setting by comparing prescreening heavy drinking questions and AUDIT scores over time. Because instrument stability is equal to test–retest reliability at worst, investigating the stability of the AUDIT would help better understand patient behavior change in context and the appropriateness of the AUDIT in a clinical setting.

Methods

This was a retrospective exploratory analysis of Visit 1 to Visit 2 AUDIT stability (n=1,099; male [75.4%], female [24.6%]) from all patients with first-time and second-time records in the Iowa Screening, Brief Intervention, and Referral to Treatment project, October 2012 to July 7, 2015 (N=17,699; male [40.6%], female [59.4%]).

Results

The AUDIT demonstrated moderate stability (intraclass correlation=0.56, 95% confidence interval: 0.52–0.60). In a multiple regression predicting the (absolute) difference between the two AUDIT scores, the participants’ age was highly significant, t(1,092)=6.23, p<0.001. Younger participants clearly showed less stability than their older counterparts. Results are limited/biased by the observational nature of the study design and the use of clinical service data.

Conclusion

The present findings contribute to the literature by demonstrating that the AUDIT changes are moderately dependable from Visit 1 to Visit 2 while taking into account patient drinking behavior variability. It is important to know the stability of the AUDIT for continued use in Screening, Brief Intervention, and Referral to Treatment programming.

Percentile ranks and benchmark estimates of change for the Health Education Impact Questionnaire: Normative data from an Australian sample

Objective:

Participant self-report data play an essential role in the evaluation of health education activities, programmes and policies. When questionnaire items do not have a clear mapping to a performance-based continuum, percentile norms are useful for communicating individual test results to users. Similarly, when assessing programme impact, the comparison of effect sizes for group differences or baseline to follow-up change with effect sizes observed in relevant normative data provides more directly useful information compared with statistical tests of mean differences and the evaluation of effect sizes for substantive significance using universal rule-of-thumb such as those for Cohen’s ‘d’. This article aims to assist managers, programme staff and clinicians of healthcare organisations who use the Health Education Impact Questionnaire interpret their results using percentile norms for individual baseline and follow-up scores together with group effect sizes for change across the duration of typical chronic disease self-management and support programme.

Methods:

Percentile norms for individual Health Education Impact Questionnaire scale scores and effect sizes for group change were calculated using freely available software for each of the eight Health Education Impact Questionnaire scales. Data used were archived responses of 2157 participants of chronic disease self-management programmes conducted by a wide range of organisations in Australia between July 2007 and March 2013.

Results:

Tables of percentile norms and three possible effect size benchmarks for baseline to follow-up change are provided together with two worked examples to assist interpretation.

Conclusion:

While the norms and benchmarks presented will be particularly relevant for Australian organisations and others using the English-language version of the Health Education Impact Questionnaire, they will also be useful for translated versions as a guide to the sensitivity of the scales and the extent of the changes that might be anticipated from attendance at a typical chronic disease self-management or health education programme.

Appraisal assessment in patient-reported outcome research: methods for uncovering the personal context and meaning of quality of life

BACKGROUND

Recent work on patient-reported outcomes (PROs) focuses on precise, brief measures, which generally convey little about what an individual's rating actually means. Individual differences in appraisal are important and relevant to PRO research. This paper highlights the advantages of integrating appraisal assessment into clinical research.

METHODS

The most comprehensive method for assessing appraisal, the quality of life (QOL) Appraisal Profile, includes open-ended and multiple choice questions to assess four appraisal parameters: frame of reference, sampling of experience, standards of comparison, and combinatory algorithm. We illustrate with empirical findings four classes of investigation that would benefit from appraisal assessment: methodological, interpretation of change, the backstory of resilience, and clinical applications.

RESULTS

A methodological investigation of HIV/AIDS patients revealed a range of cognitive schemas induced by the then-test response shift detection method, only 15% of which reflected the presumed process invoked. In this same study and in a study of people with multiple sclerosis (MS), interpretation of change in positive versus negative mental-health response shifts was characterized by different appraisal processes. In studying resilience in MS patients, patients with more reserve-building activities were more likely to use appraisals that emphasized the positive and more controllable aspects of their illness experience, as compared to lower-reserve patients. In underserved cancer patients, the QOL Appraisal Profile was used as a clinical interview to articulate current concerns and for personalized treatment decision-making to reduce burden and promote adherence.

CONCLUSIONS

Integrating appraisal assessment can provide a more textured, person-centered understanding of person-factors not captured by standard PROs.

Body composition and functional assessment of nutritional status in adults: a narrative review of imaging, impedance, strength and functional techniques

The accurate and valid assessment of body composition is essential for the diagnostic evaluation of nutritional status, identifying relevant outcome measures, and determining the effectiveness of current and future nutritional interventions. Developments in technology and our understanding of the influences of body composition on risk and outcome will provide practitioners with new opportunities to enhance current practice and to lead future improvements in practice. This is the second of a two-part narrative review that aims to critically evaluate body composition methodology in diverse adult populations, with a primary focus on its use in the assessment and monitoring of under-nutrition. Part one focused on anthropometric variables [Madden and Smith (2016) J Hum Nutr Diet 29: 7-25] and part two focuses on the use of imaging techniques, bioelectrical impedance analysis, markers of muscle strength and functional status, with particular reference to developments relevant to practice.

Advancing Symptom Science Through Use of Common Data Elements

BACKGROUND

Use of common data elements (CDEs), conceptually defined as variables that are operationalized and measured in identical ways across studies, enables comparison of data across studies in ways that would otherwise be impossible. Although healthcare researchers are increasingly using CDEs, there has been little systematic use of CDEs for symptom science. CDEs are especially important in symptom science because people experience common symptoms across a broad range of health and developmental states, and symptom management interventions may have common outcomes across populations.

PURPOSES

The purposes of this article are to (a) recommend best practices for the use of CDEs for symptom science within and across centers; (b) evaluate the benefits and challenges associated with the use of CDEs for symptom science; (c) propose CDEs to be used in symptom science to serve as the basis for this emerging science; and (d) suggest implications and recommendations for future research and dissemination of CDEs for symptom science.

DESIGN

The National Institute of Nursing Research (NINR)-supported P20 and P30 Center directors applied published best practices, expert advice, and the literature to identify CDEs to be used across the centers to measure pain, sleep, fatigue, and affective and cognitive symptoms.

FINDINGS

We generated a minimum set of CDEs to measure symptoms.

CONCLUSIONS

The CDEs identified through this process will be used across the NINR Centers and will facilitate comparison of symptoms across studies. We expect that additional symptom CDEs will be added and the list will be refined in future work.

CLINICAL RELEVANCE

Symptoms are an important focus of nursing care. Use of CDEs will facilitate research that will lead to better ways to assist people to manage their symptoms.

Integrating Social-Contextual and Intrapersonal Mechanisms of "Maturing Out": Joint Influences of Familial-Role Transitions and Personality Maturation on Problem-Drinking Reductions

BACKGROUND

"Maturing out" of problem drinking is associated with both role transitions (e.g., getting married) and personality development. However, little is known concerning how these 2 mechanisms jointly influence problem-drinking desistance. This study investigated whether salutary effects of role transitions and personality occur at different points in young-adult development and whether they mediate one another's effects.

METHODS

Participants were initially recruited as first-year undergraduates, with family history of alcoholism overrepresented by design (N = 489). Using 4 waves of data at roughly ages 21, 25, 29, and 34, cross-lagged panel models estimated prospective relations among familial-role transitions (marriage or parenthood), personality (disinhibition, conscientiousness, and neuroticism), and problem drinking.

RESULTS

Mixed support was found for the prediction of roles being more strongly associated with earlier maturing out of problem drinking and personality being more strongly associated with later maturing out. Regarding mediation, no evidence was found for the expectation that role effects would be mediated by personality. However, results did support mediation of personality effects by role transitions. Specifically, lower disinhibition and higher conscientiousness in emerging adulthood predicted role adoption, which, in turn, predicted later problem-drinking reductions. Family history of alcoholism also distally influenced these mediation processes.

CONCLUSIONS

The differential timing of role and personality effects is consistent with the notion of decreasing contextual influences and increasing intrapersonal influences across development. In light of role incompatibility theory, results suggest that, over the course of development, the association of familial roles with problem drinking may increasingly reflect problem-drinking effects on role entry (i.e., role selection) and decreasingly reflect role entry effects on problem drinking (i.e., role socialization). As emerging-adult disinhibition and conscientiousness were associated with an apparent developmental cascade of both direct and indirect effects, findings highlight their potential importance as etiologic mechanisms and intervention targets.

A new perspective on proxy report: Investigating implicit processes of understanding through patient-proxy congruence

BACKGROUND

Utilizing proxy report is a common solution to gathering quality-of-life information from people who are not capable of reliably answering questionnaires, such as people with dementia. Proxy report could, however, also provide information about patients' implicit processes of understanding, which we define as automatic, schema-driven cognitive processes that allow one to have a better understanding of oneself and of one's body, make oneself known and knowable to members of the social network, and allow one to react proactively in response to cues. We investigated whether implicit processes of understanding explain some of the association between reserve and healthy lifestyle behaviors.

METHODS

We operationalized three implicit processes of understanding: (a) psychosocial understanding; (b) insight into physical disability; and (c) somatic awareness. This secondary analysis involved a cohort of multiple sclerosis patients and their caregiver informants (n = 118 pairs). Measures included a neurologist-administered Expanded Disability Status Scale, patient- and informant-completed survey measures, and a heartbeat perception test (interoception). Patient-other congruence assessed implicit processes of understanding: psychosocial understanding (neurocognitive and personality); physical-disability insight; and somatic awareness (interoception).

RESULTS

Effect sizes (ES) for the inter-correlations between the three implicit processes were small. Psychosocial understanding was associated with higher past reserve-building activities (small ES). Psychosocial understanding explained variance in healthy lifestyle behaviors over and above the variance explained by current reserve-building activities (∆R (2) = 0.04; model R Adjusted (2) = 0.18).

CONCLUSIONS

Proxy versus patient report can provide information about underlying interpretational processes related to insight. These processes are distinct from reserve, predict health outcomes, and can inform lifestyle-changing interventions.

Factor structure and measurement invariance of the Health Education Impact Questionnaire: Does the subjectivity of the response perspective threaten the contextual validity of inferences?

OBJECTIVE

On-going evidence is required to support the validity of inferences about change and group differences in the evaluation of health programs, particularly when self-report scales requiring substantial subjectivity in response generation are used as outcome measures. Following this reasoning, the aim of this study was to replicate the factor structure and investigate the measurement invariance of the latest version of the Health Education Impact Questionnaire, a widely used health program evaluation measure.

METHODS

An archived dataset of responses to the most recent version of the English-language Health Education Impact Questionnaire that uses four rather than six response options (N = 3221) was analysed using exploratory structural equation modelling and confirmatory factor analysis appropriate for ordered categorical data. Metric and scalar invariance were studied following recent recommendations in the literature to apply fully invariant unconditional models with minimum constraints necessary for model identification.

RESULTS

The original eight-factor structure was replicated and all but one of the scales (Self Monitoring and Insight) was found to consist of unifactorial items with reliability of ⩾0.8 and satisfactory discriminant validity. Configural, metric and scalar invariance were established across pre-test to post-test and population sub-groups (sex, age, education, ethnic background).

CONCLUSION

The results support the high level of interest in the Health Education Impact Questionnaire, particularly for use as a pre-test/post-test measure in experimental studies, other pre-post evaluation designs and system-level monitoring and evaluation.

Semantic primes theory may be helpful in designing questionnaires such as to prevent response shift

OBJECTIVES

The purpose of randomized control trials (RCTs) can be the assessment of the direct effect of treatment on health-related quality of life (HRQL). Response shift (RS) theory considers that a change in HRQL scores observed over time cannot be explained solely by a direct effect of a medical condition, it may also result from a change in the way people appraise their HRQL. The RS effect is a potential bias that is liable to compromise efficient assessment of the effect of treatment on HRQL.

STUDY DESIGN AND SETTING

We hypothesize a link between the RS effect on HRQL scores and the level of complexity of HRQL conceptualization.

RESULTS

We discuss how the impact of reconceptualization on scores depends on the complexity of the linguistic definition of a subjective construct and how for reprioritization the impact depends on the dimensionality. The linguistic theory of semantic primes is used to help identify how subjective constructs can be classified according to the complexity of their definitions.

CONCLUSION

Finally, we suggest that the impact of the RS effect on HRQL scores could be avoided (or lessened) if questionnaires were designed with a rule of "the least semantic and psychometric complexity" in mind.

Physical functioning in patients with ankylosing spondylitis: comparing approaches of experienced ability with self-reported and objectively measured physical activity

BACKGROUND

Physical functioning can be assessed by different approaches that are characterized by increasing levels of individual appraisal. There is insufficient insight into which approach is the most informative in patients with ankylosing spondylitis (AS) compared with control subjects.

OBJECTIVE

The objective of this study was to compare patients with AS and control subjects regarding 3 approaches of functioning: experienced ability to perform activities (Bath Ankylosing Spondylitis Functional Index [BASFI]), self-reported amount of physical activity (PA) (Baecke questionnaire), and the objectively measured amount of PA (triaxial accelerometer).

METHODS

This case-control study included 24 AS patients and 24 control subjects (matched for age, gender, and body mass index). Subjects completed the BASFI and Baecke questionnaire and wore a triaxial accelerometer. Subjects also completed other self-reported measures on disease activity (Bath AS Disease Activity Index), fatigue (Multidimensional Fatigue Inventory), and overall health (EuroQol visual analog scale).

RESULTS

Both groups included 14 men (58%), and the mean age was 48 years. Patients scored significantly worse on the BASFI (3.9 vs 0.2) than their healthy peers, whereas PA assessed by Baecke and the accelerometer did not differ between groups. Correlations between approaches of physical functioning were low to moderate. Bath Ankylosing Spondylitis Functional Index was associated with disease activity (r = 0.49) and physical fatigue (0.73) and Baecke with physical and activity related fatigue (r = 0.54 and r = 0.54), but total PA assessed by accelerometer was not associated with any of these experience-based health outcomes.

CONCLUSIONS

Different approaches of the concept physical functioning in patients with AS provide different information. Compared with matched control subjects, patients with AS report more difficulties but report and objectively perform the same amount of PA.

Engaging patients to recover life projectuality: an Italian cross-disease framework

PURPOSE

Chronic disease is recognized as having a large impact on patient quality of life (QoL), which can be defined as an individual's satisfaction or happiness with life in domains he or she considers important. Policy makers and clinicians recognize increasingly that patients can safeguard their QoL by making healthy lifestyle choices and being actively engaged in their health care. However, in the emphasis on promoting patient engagement to enhance patients' QoL, there is no consensus regarding the relationship between QOL and patient engagement, resulting in a lack of shared guidelines among clinicians on interventions. Furthermore, no studies have provided an in-depth exploration of the perspective of patients with chronic conditions who are engaged in their health care and their requirements to achieve an improved QoL. Given this theoretical gap, the present study attempted to explore the patient engagement experience and its relationship with patient QoL in the context of the Italian healthcare system and in relation to different chronic diseases.

METHODS

In-depth qualitative interviews on a sample of 99 patients with a wide variety of chronic conditions (heart failure, chronic obstructive pulmonary disease, stroke, diabetes, and cancer).

RESULTS

Patient engagement in health care can be defined as a context-based and cross-disease process that appears to enable patients to recover their life projectuality, which had been impaired by the onset of chronic disease. Successful patient engagement may also be related to a positive shift in the ways in which patients perceive self and life and experience empowerment to realize their life potential, thus improving quality of life. Patient engagement is a powerful concept capable of reflecting significant psychosocial changes that promote patient QoL along the care process. There appears to be theoretical and empirical justification for a broad definition of QoL.

CONCLUSIONS

QoL deeply depends on the patient ability to engage in their care and on the health expectations they have. We propose a model of the relation between patient engagement and patients' trajectories in critical event responses and use it to illustrate a new perspective on QoL. This research showed the heuristic value patient engagement as a is a key concept in the promotion of a patients' experience-sensitive QoL interventions and assessment measures.

Feeling in control: comparing older people's experiences in different care settings

The promotion of choice and control for older people is a policy priority for social care services in the United Kingdom and is at the heart of recent drives to personalise services. Increasingly, we are seeing a move away from institutionalised care (e.g. in care homes) towards enablement, with more services being delivered in community-based settings. Extra care housing has been promoted as a purpose-built, community-based alternative to residential care for older people. However, whilst accounts of users' experiences in particular service types are plentiful, the use of different instrumentation and measures makes comparison between settings difficult. We combined data from four studies where participants were older people either living in care homes or extra care housing or receiving care at home. All of these studies asked participants to rate their control over daily life, using the Adult Social Care Outcomes Toolkit (ASCOT). This paper presents the results of an ordinal logistic regression analysis indicating that, after controlling for differences in age, ability to perform activities of daily living and self-rated health, setting had a significant effect on older people's sense of control. Residents in care homes and extra care housing report similar levels of control over daily life but consistently report feeling more in control than older people receiving care at home. Implications for policy and practice are discussed.

Minimal evidence of response shift in the absence of a catalyst

BACKGROUND

Individuals with chronic conditions experience fluctuations in health status and thus may experience response shift. We sought to test the hypothesis that response shift effects would be non-significant among individuals with chronic disease who experienced relatively small changes in their health status over a 1-year period.

METHODS

This secondary analysis utilized longitudinal cohort data on a community-based sample (n = 776) representing four chronic diseases (arthritis, heart failure, diabetes, or chronic obstructive pulmonary disease). Information on health-care utilization was obtained from the provincial health insurance database. Participants completed the SF-36 twice annually. Parameter invariance over 1 year in a second-order SF-36 factor structure was evaluated by adapting Oort's approach by fitting a second-order measurement structure with first-order factors for the SF-36 subscales and second-order factors for physical and mental health status while accommodating ordinal data.

RESULTS

Over 80 % of participants had no hospitalizations or emergency room visits over follow-up. The model had an acceptable fit when all measurement model parameters were constrained at both time points (RMSEA = .035, CFI = .97). There was no substantial difference in fit when measurement model parameters (item thresholds, first-order factor intercepts, and factor loadings) were allowed to vary over time.

CONCLUSION

Among chronically ill individuals with stable health, substantial response shift effects were not detected. These results support the theoretical proposition that response shift is not expected to occur in patients with relatively stable conditions.

Shifting responses in quality of life: people living with dialysis

PURPOSE

People assess their quality of life (QoL) using internal standards, values, and priorities. With health changes, QoL responses shift to reflect current realities. This qualitative study investigated the life experience and QoL assessments of people living with dialysis (PWDs).

METHODS

Thirty-one interviews with 20 PWDs over the age of 70 (mean time on dialysis 34 months) and 11 family members investigated experience with disease and dialysis, related life challenges, medical decision-making, and future planning. Interviews were recorded, transcribed, and analyzed for themes and hypotheses using qualitative methods and description.

RESULTS

When beginning dialysis, PWDs' reported that life on dialysis was worth living and recalibrated their QoL assessments incorporating this standard into their daily lives. Three themes emerged as the disease progressed and dialysis became more difficult: PWDs first reported thriving on dialysis and then surviving with the support of dialysis, and when QoL was reported as poor, PWDs were reconsidering whether dialysis was still worth the life it was providing. Each of these steps involved changes in health circumstances, and PWDs explained their QoL assessments at each step using differing values and priorities. These steps in reconceptualization and reprioritization demonstrated PWDs' Response Shift and eventually led to another (recalibrated) standard: Life with dialysis was no longer worth living.

CONCLUSIONS

Quality-of-life assessment is an on-going process for older dialysis patients. Clinicians should be alert for changes in subjective QoL statements as dialysis and underlying diseases progress. Response Shift explains these changes in assessment.

Direkte Veränderungsmessung in der Psychotherapie

Theoretischer Hintergrund: Verfahren zur direkten Veränderungsmessung bestimmen den Psychotherapieerfolg in ökonomischer Ein-Punkt-Messung. Hierzu wurde der Bochumer Veränderungsbogen-2000 (BVB-2000) als überarbeitete und gekürzte Variante des Veränderungsfragebogens des Erlebens und Verhaltens (VEV; Zielke & Kopf-Mehnert, 1978 ) entwickelt. Fragestellung: Der BVB-2000 soll einer testtheoretischen Reanalyse mit Fokus auf die konvergente Validität unterzogen werden. Kritische Veränderungswerte auf Basis der Werte einer klinischen Wartekontrollgruppe sollen die Möglichkeit bieten den Therapieerfolg auch in Einzelfällen zu bestimmen. Methode: Die Psychotherapie von N = 205 Patienten wird mit verschiedenen Instrumenten zur Therapieerfolgsmessung inklusive des BVB-2000 begleitet. Auf Basis einer Wartekontrollgruppe (N = 88) werden kritische Veränderungswerte für den BVB-2000 berechnet. Ergebnisse: Der BVB-2000 weist eine hohe interne Konsistenz auf (α = .96; 26 Items) und zeigt durchgängig statistisch bedeutsame Zusammenhänge mit anderen Therapieerfolgsmaßen vor allem der Zielerreichung. Kritische Veränderungswerte ermöglichen die Einschätzung des Therapieerfolgs im Einzelfall. Schlussfolgerungen: Der BVB-2000 ist ein verständliches, ökonomisches, reliables und valides Instrument zur Psychotherapieerfolgsmessung.

Reasons why multimorbidity increases the risk of participation restriction in older adults with lower extremity osteoarthritis: a prospective cohort study in primary care

OBJECTIVE

To determine why multimorbidity causes participation restriction in adults ages ≥50 years who consult primary care with lower extremity osteoarthritis (OA).

METHODS

This was a population-based prospective cohort study of 1,053 consulters for lower extremity OA who were free of participation restriction at baseline. Path analysis was used to test proposed mechanisms by examining for mediation of the association between multimorbidity at baseline, defined by self-report and consultation data separately, and incident participation restriction at 3 years by lower extremity pain severity, obesity, locomotor disability, and depression.

RESULTS

Multimorbidity was associated with incident participation restriction (adjusted odds ratio [OR] 2.83, 95% confidence interval [95% CI] 2.03-3.94 for multimorbidity [self-report]; OR 1.59, 95% CI 1.15-2.21 for multimorbidity [consultation data]). The extent of mediation of the association of baseline multimorbidity, defined by self-report, and incident participation restriction was greater for severe lower extremity pain than obesity (standardized beta coefficients for indirect effect 0.032 [SE 0.015] and 0.020 [SE 0.019], respectively). The addition of depression and locomotor disability increased the amount of mediation (0.115 [SE 0.028]) and reduced the proportion explained by severe lower extremity pain (0.014 [SE 0.015]) and obesity (0.006 [SE 0.010]). Locomotor disability was the strongest mediator.

CONCLUSION

The additional impact on participation in social and domestic life that multimorbidity places on individuals with lower extremity OA appears to be mediated through further restriction of locomotor disability, as well as through depression. The results suggest that the effect of multimorbidity on the daily lives of people with lower extremity OA will be ameliorated by active management of depression and locomotor disability.

Fluctuations in appraisal over time in the context of stable versus non-stable health

PURPOSE

This study seeks to estimate clinically significant change in quality of life (QOL) appraisal by comparing changes in appraisal over 6 months of follow-up in people with multiple sclerosis who experienced no change in symptoms versus those with worsening symptoms. This estimation is important for enabling valid interpretation of longitudinal change, both in terms of ensuring the comparison of scores and for response shift estimation.

METHODS

This is a secondary analysis of longitudinal data (N = 859) of participants in the North American Research Committee on Multiple Sclerosis registry. Patient groupings were characterized on the basis of self-reported symptom change over 1 year of follow-up and compared in terms of their responses to the QOL Appraisal Profile. Bonferroni adjustments reduced the type I error rate, and interpretation was restricted to those comparisons with small or larger effect sizes using Cohen's criteria.

RESULTS

The Symptoms Unchanged group evidenced more change in Frame of Reference goal delineation themes and Combinatory Algorithm, whereas the Symptoms Worse group evidenced more change in Sampling of Experience and Standards of Comparison items. The group differences were, however, not large or statistically significant in most cases, likely due to being under-powered to detect interaction effects.

CONCLUSIONS

Many aspects of appraisal are relatively constant in the context of unchanging and changing symptom experience, but symptom changes led patients to make substantial shifts in what experiences they sample when thinking about their health-related QOL. These underlying cognitive processes may help people to maintain homeostasis in their perceived QOL.

Es ging mir schlechter, als ich dachte!

Theoretischer Hintergrund: Bei retrospektiven Einschätzungen des Erlebens und Verhaltens werden meist Gedächtnis- und Urteilsfehler vermutet. Fragestellung: Wie zuverlässig sind retrospektive Symptomeinschätzungen in der Psychotherapie? Wie valide sind Therapieerfolgsmaße auf Basis retrospektiver Symptomeinschätzungen? Methode: Psychotherapiepatienten (N = 83) rekonstruieren zu Therapieende ihre Symptomausprägung vom Beginn der Therapie auf dem Brief Symptom Inventory (BSI) und dem Beck Depressions Inventar (BDI). Ergebnisse: Neben einer bedeutsamen retrospektiven Überschätzung zeigen retrospektive und reguläre Prä-Messungen bedeutsame Zusammenhänge. Das Ausmaß der retrospektiven Symptomeinschätzungen ist vom Therapieerfolg weitgehend unabhängig. Prä-Post Effektstärken auf Basis der retrospektiven Prä-Messungen zeigen vergleichbare Zusammenhänge mit anderen Therapieerfolgsmaßen wie reguläre Prä-Post Effektstärken. Schlussfolgerungen: Retrospektive Symptomeinschätzungen sind zuverlässig aber nicht akkurat. Pauschale Annahmen über Urteilsfehler und eine wenig valide Darstellung des Therapieerfolgs bei retrospektiver Erfassung von Symptomen müssen zurückgewiesen werden.

Ziel erreicht! Aber auch verändert?

Theoretischer Hintergrund: In faktorenanalytischen Untersuchungen verschiedener Psychotherapieerfolgswerte resultieren meist sogenannte Methodenfaktoren. Hierbei lassen sich Zwei-Punkt-Messungen (Prä-Post) von Ein-Punkt-Messungen zu Therapieende (Post) trennen. Einige Studien betrachten diese Divergenz der Erfolgswerte als Ergebnis einer unterschiedlichen Zeitperspektive (Veränderungsmaße versus retrospektive Erfolgsbeurteilungen). Fragestellung: Ist die unterschiedliche Zeitperspektive tatsächlich für die Divergenz der Erfolgswerte verantwortlich? Methode: Über vorhandene Studien hinausgehend werden Patienten (N = 59) aufgefordert ihre Prä-Werte zu Therapieende abermals retrospektiv zu schätzen (Retro). Retro-Post Differenzwerte werden als retrospektives Maß der Veränderung zusätzlich in eine Faktorenanalyse verschiedener Erfolgswerte einbezogen. Ergebnisse: Es lässt sich eine zweifaktorielle Struktur mit den Komponenten „Veränderung” und „Restsymptomatik/Zielerreichung” zeigen. Verschiedene retrospektive Strategien müssen unterschiedlichen Faktoren zugeordnet werden. Schlussfolgerungen: Differenzwerte (Prä-Post, Retro-Post) lassen sich komplementär von einer subjektiven Heuristik der Erfolgsbeurteilung abgrenzen, die einen Abgleich von aktuellem Befinden und Zielvorstellungen vornimmt. Hierbei spielt die Retrospektivität der Erhebung–also die Zeitperspektive–nur eine untergeordnete Rolle.

Using the random forest method to detect a response shift in the quality of life of multiple sclerosis patients: a cohort study

Background

Multiple sclerosis (MS), a common neurodegenerative disease, has well-described associations with quality of life (QoL) impairment. QoL changes found in longitudinal studies are difficult to interpret due to the potential response shift (RS) corresponding to respondents’ changing standards, values, and conceptualization of QoL. This study proposes to test the capacity of Random Forest (RF) for detecting RS reprioritization as the relative importance of QoL domains’ changes over time.

Methods

This was a longitudinal observational study. The main inclusion criteria were patients 18 years old or more with relapsing-remitting multiple sclerosis. Every 6 months up to month 24, QoL was recorded using generic and MS-specific questionnaires (MusiQoL and SF-36). At 24 months, individuals were divided into two ‘disability change’ groups: worsened and not-worsened patients. The RF method was performed based on Breiman’s description. Analyses were performed to determine which QoL scores of SF-36 predicted the MusiQoL index. The average variable importance (AVI) was estimated.

Results

A total of 417 (79.6%) patients were defined as not-worsened and 107 (20.4%) as worsened. A clear RS was identified in worsened patients. While the mental score AVI was almost one third higher than the physical score AVI at 12 months, it was 1.5 times lower at 24 months.

Conclusion

This work confirms that the RF method offers a useful statistical approach for RS detection. How to integrate the RS in the interpretation of QoL scores remains a challenge for future research.

Trial registration

ClinicalTrials.gov identifier: NCT00702065

Measurement Validity is Fundamentally a Matter of Definition, Not Correlation

Correlations between sets of measurements produced by several measures can be determinative of the validity of these measures only insofar as theories about how these measurements relate in correlation and regression terms are already known to be true. However, scientific theories can only be known to be true insofar as they have already been demonstrated to be true by valid measurements. Therefore, only the nature of a measure that produces the measurements for representing a dimension can justify claims that these measurements are valid for that dimension, and this is ultimately exclusively a matter of the normative definition of that dimension in the science that involves that dimension. Thus, contrary to the presently prevailing theory of construct validity, a measure's measurements themselves logically cannot at all indicate their own validity or invalidity by how they relate to other measures' measurements unless these latter are already known to be valid and the theories represented by all these several measures' measurements are already known to be true. It is only the conformity of a measure to the normative conceptual analysis and so definition of a dimension that can make the measurements it produces valid measurements on that dimension. This makes it essential for each basic science to achieve normative conceptual analyses and definitions for each of the dimensions in terms of which it describes and causally explains its phenomena.

Measurement issues in the evaluation of chronic disease self-management programs

OBJECTIVES

To provide an in-depth analysis of outcome measures used in the evaluation of chronic disease self-management programs consistent with the Stanford curricula.

METHODS

Based on a systematic review on self-management programs, effect sizes derived from reported outcome measures are categorized according to the quality of life appraisal model developed by Schwartz and Rapkin which classifies outcomes from performance-based measures (e.g., clinical outcomes) to evaluation-based measures (e.g., emotional well-being).

RESULTS

The majority of outcomes assessed in self-management trials are based on evaluation-based methods. Overall, effects on knowledge--the only performance-based measure observed in selected trials--are generally medium to large. In contrast, substantially more inconsistent results are found for both perception- and evaluation-based measures that mostly range between nil and small positive effects.

CONCLUSIONS

Effectiveness of self-management interventions and resulting recommendations for health policy makers are most frequently derived from highly variable evaluation-based measures, that is, types of outcomes that potentially carry a substantial amount of measurement error and/or bias such as response shift. Therefore, decisions regarding the value and efficacy of chronic disease self-management programs need to be interpreted with care. More research, especially qualitative studies, is needed to unravel cognitive processes and the role of response shift bias in the measurement of change.

Health-related quality of life differences between African Americans and non-Hispanic whites with head and neck cancer

BACKGROUND

Cancers of the head and neck are associated with detriments in health-related quality of life (HRQOL); however, little is known about different experiences between African Americans and non-Hispanic whites.

METHODS

HRQOL was measured by the Functional Assessment of Cancer Therapy - Head and Neck (FACT-H&N) approximately 5 months postdiagnosis among 222 patients with cancer from North Carolina. Higher scores represent better HRQOL. Regression models included sociodemographic characteristics and clinical factors.

RESULTS

African Americans reported higher physical well-being than whites (adjusted means, 23.1 vs 20.9). African Americans with incomes <$20,000 reported higher emotional well-being (21.4) and fewer head and neck symptoms (22.0). Non-Hispanic whites making <$20,000 reported the poorest emotional well-being (17.3), whereas African Americans making >$20,000 reported the most head and neck symptoms (18.7).

CONCLUSIONS

Further investigation is needed to explore variation in HRQOL experiences among different race and socioeconomic groups that may inform resource allocation to improve cancer care.

Quality of life is a process not an outcome

Quality improvement mechanisms increasingly use outcome measures to evaluate health care providers. This move toward outcome measures is a radical departure from the traditional focus on process measures. More radical still is the proposal to shift from relatively simple and proximal measures of outcome, such as mortality, to complex outcomes, such as quality of life. While the practical, scientific, and ethical issues associated with the use of outcomes such as mortality and morbidity to compare health care providers have been well rehearsed, the specific concerns associated with the use of quality of life measures in quality of care research have received little attention. As with much research on quality of life there is a tendency to assume that the disadvantages are outweighed by the general virtue of "listening" to patients. In this paper we disagree with this assumption and argue that quality of life is a process, not an outcome.

Felicitometric hermeneutics: interpreting quality of life measurements

The use of quality of life (QOL) outcomes in clinical trials is increasing as a number of practical, ethical, methodological, and regulatory reasons for their use have become apparent. It is important, then, that QOL measurements and differences between QOL scores be readily interpretable. We study interpretation in two contexts: when determining QOL and when basing decisions on QOL differences. We consider both clinical situations involving individual patients and research contexts, e.g., randomized clinical trials, involving groups of patients. We note the ethical importance of such understanding: proper interpretation and communication facilitate health care decision making. Communication that facilitates interpretation is of moral significance since better communication can attenuate ethical problems and inform choices. Much of what is communication worthy about QOL assessments is determined by the particular QOL instrument used in the assessment and how it is administered. In practice, these choices will be driven by the purpose of the assessment, but, it is argued, to maximize understanding, we should combine the information garnered from traditional standardized QOL instruments, from individualized QOL assessments, and from a recently proposed dialogic paradigm, where QOL is determined by shared conversation regarding the interpretation of texts. And, while some studies can surely succeed using abbreviated methods of administration (e.g., postal surveys may suffice for certain purposes), we will focus on methods of administration involving interviewer-respondent interaction. We suggest that during the QOL elicitation process, interviewer and respondent should engage in a two-way conversation in order to achieve a shared understanding of the "answers" to QOL "questions" and, finally, to reach a shared interpretation of the individual's QOL.

Cross-cultural adaptation and measurement properties of the Brief Illness Perception Questionnaire-Dutch Language Version

OBJECTIVE

Ever since Engel's Biopsychosocial Model (1977) emotions, thoughts, beliefs and behaviors are accepted as important factors of health. The Brief Illness Perception Questionnaire (Brief IPQ) assesses these beliefs. Aim of this study was to cross-culturally adapt the Brief IPQ into the Brief IPQ Dutch Language Version (Brief IPQ-DLV), and to assess its face validity, content validity, reproducibility, and concurrent validity.

METHODS

Beaton's guideline was used for cross-culturally adaptation. Face and content validity were assessed in 25 patients, 15 physiotherapists and 24 first-grade students. Reproducibility was established in 27 individuals with chronic obstructive pulmonary disease using Cohen's kappa coefficient (K(w)) and the Smallest Detectable Change (SDC). Concurrent validity was assessed in 163 patients visiting 11 different physical therapists.

RESULTS

The Brief IPQ-DLV is well understood by patients, health care professionals and first-grade students. Reliability at 1 week for the dimensions Consequences, Concern and Emotional response K(w)>0.70, for the dimensions Personal control, Treatment control, Identity, K(w)<0.70. A time interval of 3 weeks, reliability coefficients were lower for almost all dimensions. SDC was between 2.45 and 3.37 points for individual measurement purposes and between 0.47 and 0.57 points for group evaluative measurement purposes. Concurrent validity showed significant correlations (P<.05) for four out of eight illness perceptions (IPs) dimensions.

CONCLUSION

The face and content properties were found to be acceptable. The reproducibility and concurrent validity needs further investigated.

Health-related quality of life after stroke: does response shift occur in self-perceived physical function?

OBJECTIVE

To determine whether response shift (a change in the self-perceived meaning of health-related quality of life [HRQL]) was present in a model of physical function over time poststroke.

DESIGN

Secondary data analysis of a longitudinal observational study.

SETTING

Community.

PARTICIPANTS

A consecutive sample of stroke survivors (N=677) at 1, 3, 6, and 12 months poststroke was included. Sixty-seven individuals were approached, but refused. Sixty-seven percent completed the study at 12 months. Mean age was 68 years; 45% of the participants were women.

INTERVENTIONS

Not applicable.

MAIN OUTCOMES MEASURES

The Medical Outcomes Study 36-Item Short-Form Health Survey, Euroqol, Stroke Impact Scale, Preference-Based Stroke Index, and the Health Utilities Index.

RESULTS

Structural equation modeling was used to identify response shift. A chi-square difference test between constrained and unconstrained longitudinal models suggested the presence of response shift in the data. Reprioritization response shift, a change in relative importance of domains, was observed for physical activites. Recalibration response shift, a change in internal standards of measurement, was observed in physical activities, stairs, walking, and hand function.

CONCLUSIONS

Response shift has implications for the measurement of change in physical function. Measures that focus on difficulty in task performance may be sensitive to response shift, resulting in a change in perceived HRQL over time. This has implications for choosing self-perceived or performance-based measures to detect change in physical function.

Response shift in patients with multiple sclerosis: an application of three statistical techniques

OBJECTIVE

With the evolution of theory and methods for detecting recalibration, reprioritization, and reconceptualization response shifts, the time has come to evaluate and compare the current statistical detection techniques. This manuscript presents an overview of a cross-method validation done on the same patient sample.

METHODS

Three statistical techniques were used: Structural Equation Modeling, Latent Trajectory Analysis, and Recursive Partitioning and Regression Tree modeling. The study sample (n = 3,008) was drawn from the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry to represent patients soon after diagnosis, classified as having either a self-reported relapsing, progressive, or stable disease trajectory. Patient-reported outcomes included the disease-specific Performance Scales and the Patient-Derived Disease Steps, and the generic SF-12v2 measure.

RESULTS

Small response shift effect sizes were detected by all of the methods. Recalibration response shift was detected by Structural Equation Modeling, Recursive Partitioning Regression Tree demonstrated patterns consistent with all three types of response shift, and Latent Trajectory Analysis, although unable to distinguish types of response shift, did detect response shift in less than 1% of the sample.

CONCLUSION

The methods and their findings were discussed for operationalization, interpretability, assumptions, ability to use all data points from the study sample, limitations, and strengths. Directions for future research are discussed.

Response shift in quality of life assessment in patients with chronic back pain and chronic ischaemic heart disease

PURPOSE

To examine the extent and type of influence of response shift (RS) (reconceptualization, reprioritization, recalibration) on the assessment of changes in health-related quality of life (HRQoL) after the inpatient rehabilitation of patients with chronic back pain and chronic ischaemic heart disease.

METHODS

RS was assessed using the then-test and structural equation modelling (SEM) approaches. HRQoL was recorded in a questionnaire study at the start and end of rehabilitation using disease-specific instruments. Global items were also developed to collect data on HRQoL at the start and end of rehabilitation, as well as for the retrospective evaluation of HRQoL at the beginning of rehabilitation via the then-test.

RESULTS

There are small recalibration effects in the then-test in both diseases in nearly every item which may underestimate the actual effects of change. Using the SEM approach, uniform and non-uniform recalibration effects appear in a few of the scales that cause true change scores to be under- and over-estimated.

CONCLUSION

RS reflects a phenomenon that should be included when assessing HRQoL to allow a more valid interpretation of treatment effects. The results of SEM approach, however, suggest that RS does not lead to fundamentally different results in rehabilitation effects.