Methods for validating and norming translations of health status questionnaires: the IQOLA Project approach. International Quality of Life Assessment

Thai SF-36 health survey: tests of data quality, scaling assumptions, reliability and validity in healthy men and women

BACKGROUND

Since its translation to Thai in 2000, the SF-36 Health Survey has been used extensively in many different clinical settings in Thailand. Its popularity has increased despite the absence of published evidence that the translated instrument satisfies scoring assumptions, the psychometric properties required for valid interpretation of the SF-36 summated ratings scales. The purpose of this paper was to examine these properties and to report on the reliability and validity of the Thai SF-36 in a non-clinical general population.

METHODS

1345 distance-education university students who live in all areas of Thailand completed a questionnaire comprising the Thai SF-36 (Version 1). Median age was 31 years. Psychometric tests recommended by the International Quality of Life Assessment Project were used.

RESULTS

Data quality was satisfactory: questionnaire completion rate was high (97.5%) and missing data rates were low (< 1.5% for all items). The ordering of item means within scales generally were clustered as hypothesized and scaling assumptions were satisfied. Known groups analysis showed good discriminant validity between subgroups of healthy persons with differing health states. However, some areas of concern were revealed. Possible translation problems of the Physical Functioning (PF) items were indicated by the comparatively low ceiling effects. High ceiling and floor effects were seen in both role functioning scales, possibly due to the dichotomous format of their response choices. The Social Functioning scale had a low reliability of 0.55, which may be due to cultural differences in the concept of social functioning. The Vitality scale correlated better with the Mental Health scale than with itself, possibly because a healthy mental state is central to the concept of vitality in Thailand.

CONCLUSION

The summated ratings method can be used for scoring the Thai SF-36. The instrument was found to be reliable and valid for use in a general non-clinical population. Version 2 of the SF-36 could improve ceiling and floor effects in the role functioning scales. Further work is warranted to refine items that measure the concepts of social functioning, vitality and mental health to improve the reliability and discriminant validity of these scales.

Tradução e adaptação da versão brasileira do Night Eating Questionnaire

O objetivo deste estudo foi traduzir e adaptar o conteúdo do Night Eating Questionnaire e avaliar a confiabilidade da versão em português. O estudo envolveu duas fases. A primeira constituiu-se da: (1) tradução; (2) retradução para o Inglês; (3) correção e adaptação da semântica; (4) validação do conteúdo; e (5) avaliação da clareza do questionário por meio de escalas analógico-visuais de 10cm com trinta adultos de uma clínica de suporte nutricional. Na segunda, avaliou-se a confiabilidade com 100 sujeitos, cujo perfil foi similar ao da primeira etapa. Na quinta etapa, a compreensão do instrumento aferida pela escalas analógico-visuais teve média de 8,20 ± 1,55cm. Este instrumento demonstrou consistência interna satisfatória, com um coeficiente geral alfa de Cronbach = 0,78. A versão mostrou ser de fácil compreensão, obtendo-se adequada validação semântica e de consistência. Isso sugere que o instrumento pode ser adequado para screening da síndrome do comer noturno. No entanto, é necessário avaliar as características psicométricas deste instrumento em amostra com diferentes níveis sociais e educacionais.

Systematic review: health-related quality of life (HRQOL) questionnaires in gastro-oesophageal reflux disease

BACKGROUND

Although gastro-oesophageal reflux disease (GERD) has a well-established pathophysiology, the impact of GERD symptoms on the patients' quality of life can be profound. Therefore, health-related quality of life (HRQOL) questionnaires have become standard instruments to evaluate the effect of treatment in clinical trials.

AIM

To evaluate the reliability, validity and responsiveness of available GERD-specific HRQOL.

METHODS

A systematic literature search using the Medical Subject Headings terms: 'Gastro-oesophageal reflux', 'Heartburn' and 'Oesophagitis' with 'quality of life' and 'questionnaires' was preformed to identify the available HRQOL questionnaires. To analyse the psychometric properties of the respective tools, the actual guidelines for the use of patient-reported outcomes in clinical trials were applied.

RESULTS

We identified five GERD-specific HRQOL questionnaires but none of them fulfilled all quality criteria; either they did not meet the actual standards for psychometric properties (HBQOL, GERD-HRQL, Jasani et al.Aust Fam Physician 1999; 28: 515), or were impracticable to use in clinical trials. The generic and hybrid instruments lack specificity and sensitivity and were not designed for treatment evaluation in GERD patients.

CONCLUSION

There is need for a new evaluative tool in the assessment of HRQOL during GERD therapy.

Cross-cultural adaptation and validation of the `Multiple Sclerosis Quality of Life Instrument' in Hungarian

Health-related quality of life measurements are gaining more importance in the study and clinical practice of multiple sclerosis. The aim of our study was the adaptation of the Multiple Sclerosis Quality of Life Instrument (MSQOL-54) in Hungarian. The study was carried out at the Department of Neurology, University of Szeged and two other multiple sclerosis centers. The Hungarian translation of the questionnaire was given to patients at the outpatient units of the neurology departments. The EDSS score of the patients were determined and data concerning the onset and the clinical form of the disease was collected. Altogether 438 patients filled out the questionnaire. We enrolled patients with all clinical forms of the disease. Cronbach's alpha coefficients were over 0.8 in case of all scales except `Rolelimitations — emotional' (0.794), indicating a good internal consistency reliability for group comparisons. The instrument was able to distinguish between known clinical group differences. The Hungarian version of the MSQOL-54 instrument shows good psychometric properties similar to the original questionnaire. Multiple Sclerosis 2008; 14: 391—398. http://msj.sagepub.com

Effect on quality of life of continuous positive airway pressure in patients with obstructive sleep apnea syndrome: a meta-analysis

Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnea syndrome (OSAS). However, the impact of CPAP on quality of life (QOL) is controversial. The aim of this study was to systematically review and determine whether CPAP improves QOL in patients with OSAS. We performed a comprehensive literature search to identify studies published between 1966 and 2007 comparing values of CPAP with control. Weighted mean difference (WMD) was used to analyze the data. The pooled WMD was calculated by using a fixed or random-effect model. The outcomes for 1,256 patients from 16 studies, of whom 656 patients underwent CPAP and 600 were controls, were included. CPAP led to significant improvements in the Nottingham health profile part 2 (WMD=1.657; 95% CI=3.005, -0.308; p=0.016), but there was no difference in other general QOL scores. Patients undergoing CPAP scored better in physical function (WMD=3.457; 95% CI=0.144, 6.771; p=0.041), body pain (WMD=4.017; 95% CI= -0.008, 8.042; p=0.05), energy vitality (WMD=6.984; 95% CI = 0.557, 13.411; p=0.033) and physical component summary (PCS) (WMD=2.040; 95% CI=0.045, 4.035; p=0.045) using the SF-36 tool. This meta-analysis shows that CPAP does not improve general QOL scores but does improve physical domains and vitality. Study design and QOL questionnaire tools are important to capture and evaluate information efficiently. However, generic QOL instruments may not be adequate in detecting important changes in quality of life in patients with OSAS.

Comparative assessment of migrant farm worker health in conventional and organic horticultural systems in the United Kingdom

This study describes the self-reported health and well-being status of field and packhouse workers in UK vegetable horticulture, and tests the null hypothesis that there is no difference in the self-reported health of workers on organic and conventional horticultural farms. The majority of those sampled were migrant workers (93%) from Bulgaria, Latvia, Lithuania, Poland, Russia and the Ukraine. More than 95% of the respondents were aged 18-34 and recruited through university agricultural faculties in East European or employed via UK agencies. The health of 605 farm workers (395 males and 210 females) was measured through the use of four standard health instruments. Farm workers' health was significantly poorer than published national norms for three different health instruments (Short Form 36, EuroQol EQ-5D and the Visual Analogue Scale). There were no significant differences in the health status of farm workers between conventional and organic farms for any of these three instruments. However, organic farm workers scored higher on a fourth health instrument the Short Depression Happiness Scale (SDHS) indicating that workers on organic farms were happier than their counterparts working on conventional farms. Multiple regression analysis suggested that the difference in the SDHS score for organic and conventional farms is closely related to the range and number of tasks the workers performed each day. These findings suggest that a great deal of improvement in the self-reported health of farmers will need to occur before organic farms meet the requirements of the 'Principle of Health' as described by IFOAM. Ensuring that farm workers have a varied range of tasks could be a cost effective means of improving self-reported health status in both organic and conventional farming systems.

Combined effects of major depression, pain and somatic disorders on general functioning in the general adult population

This study was carried out to assess the prevalence of major depressive disorder (MDD) in persons suffering from pain symptoms in various locations, both with and without comorbid somatic disorders and to analyze the single and combined effects of MDD, pain symptoms and somatic disorders on general functioning in the community. The 12-month prevalence of MDD, somatic disorders and pain symptoms, grouped according to location, were determined among 4181 participants from a community sample. Depression was assessed utilising the Composite International Diagnostic Interview. Pain symptoms were self-reported by participants whereas medical diagnoses were validated by medical examinations. General functioning was evaluated utilising the established MOS-SF-36 scale. The prevalence of MDD was significantly increased for persons with pain in any location. In the absence of a somatic disorder, MDD prevalence was highest in persons with abdominal/chest pain (9.3%) and arm or leg pain (7.9%) and lowest in persons with back pain (6.2%). Mental and physical well-being were lowest for persons with both MDD and a somatic disorder, irrespective of pain locations. Increasing numbers of pain locations impaired mental and physical well-being across all groups, but the effect on mental well-being was most marked in participants with MDD and comorbid somatic disorders. The presence of pain increases risk of associated MDD. The number of pain locations experienced, rather than the specific location of pain, has the greatest impact on general functioning. Not only chronic pain, but pain of any type may be an indicator of MDD and decreased general functioning.

Females with Fabry disease frequently have major organ involvement: lessons from the Fabry Registry

Fabry disease (FD) is an X-linked lysosomal storage disease caused by alpha-galactosidase A deficiency. The Fabry Registry is a global clinical effort to collect longitudinal data on FD. In the past, most "carrier" females were usually thought to be clinically unaffected. A systematic effort has been made to enroll all FD females, regardless of symptomology. Of the 1077 enrolled females in the Registry, 69.4% had symptoms and signs of FD. The median age at symptom onset among females was 13 years, and even though 84.1% had a positive family history, the diagnosis was not made until a median age of 31 years. Twenty percent experienced major cerebrovascular, cardiac, or renal events, at a median age of 46 years. Among adult females with estimated glomerular filtration rate (eGFR) data (N=638), 62.5% had an eGFR <90 ml/min/1.73 m2 and 19.0% had eGFR <60 ml/min/1.73 m2. Proteinuria 300 mg/day was present in 39.0% of females, and 22.2% had >1 gram/day. Quality of life (QoL), as measured by the SF-36((R)) survey, was impaired at a later age than in males, but both genders experience significantly impaired QoL from the third decade of life onward. Thus, females with FD have a significant risk for major organ involvement and decreased QoL. Females should be regularly monitored for signs and symptoms of FD, and considered for enzyme replacement therapy.

Therapeutic Interactive Voice Response for chronic pain reduction and relapse prevention

We developed Therapeutic Interactive Voice Response (TIVR) as an automated, telephone-based tool for maintenance enhancement following group cognitive-behavioral therapy (CBT) for chronic pain. TIVR has four components: a daily self-monitoring questionnaire, a didactic review of coping skills, pre-recorded behavioral rehearsals of coping skills, and monthly personalized feedback messages from the CBT therapist based on a review of the patient's daily reports. The first three components are pre-recorded and all four can be accessed remotely by patients via touch-tone telephone on demand. Following 11 weeks of group CBT, 51 subjects with chronic musculoskeletal pain were randomized to one of two study groups. Twenty-six subjects participated in 4 months of TIVR, while a control group of 25 subjects received standard care only. The TIVR group showed maximum improvement over baseline at the 8-month follow-up for seven of the eight outcome measures; improvement was found to be significant for all outcomes (p Collapse

Key Words

• chronic pain
• coping
• ivr
• automated telephone
• cognitive behavioral therapy

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MESH Headings

• Chronic Disease
• Cognitive Behavioral Therapy/methods
• Humans
• Middle Aged
• Pain Management
• Secondary Prevention
• Self Care/methods
• Self-Assessment
• Telemedicine/methods
• Therapy, Computer-Assisted/methods

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Grants

• R21 DA016115 NIDA NIH HHS
• R01 AA014270 NIAAA NIH HHS
• R01 AR059674 NIAMS NIH HHS
• R21 DA016115-02 NIDA NIH HHS
• R01 AR052131 NIAMS NIH HHS
• R21 DA016115-01 NIDA NIH HHS

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Affiliation(s)

Magdalena R. Naylor Department of Psychiatry, University of Vermont College of Medicine, Burlington, VT
Francis J. Keefe Department of Psychiatry and Behavioral Sciences, Duke University Medical School, Durham, NC
Bart Brigidi Department of Psychiatry and Behavioral Sciences, Duke University Medical School, Durham, NC
Shelly Naud Department of Medical Biostatistics, University of Vermont, Burlington, VT
John E. Helzer Department of Psychiatry, University of Vermont College of Medicine, Burlington, VT

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Portuguese version of Corah's Dental Anxiety Scale: transcultural adaptation and reliability analysis

This study explores the psychometric properties of the Portuguese version of Corah's Dental Anxiety Scale (DAS), an instrument designed to assess the manifestations of dental anxiety. The DAS has been translated into several languages, but no adaptation and reliability analysis of the Portuguese version of the scale has yet been carried out. A total of 747 Brazilian undergraduate students participated in this study. The instrument proved to have good internal consistency and test-retest reliability. Furthermore, we observed that women are more anxious during dental treatment routines compared to men. Our findings suggest that the Portuguese version of DAS is a reliable instrument for assessing adults' dental anxiety traits, and can be used for both clinical and research purposes.

Cross-cultural adaptation of the Child Perceptions Questionnaire 11-14 (CPQ11-14) for the Brazilian Portuguese language

Background

Oral-Health-Related Quality of Life (OHRQoL) instruments are being used with increasing frequency in oral health surveys. However, these instruments are not available in all countries or all languages. The availability of cross-culturally valid, multi-lingual versions of instruments is important for epidemiological research. The Child Perceptions Questionnaire 11–14 (CPQ_11–14) is an OHRQoL instrument that assesses the impact of oral conditions on the quality of life of children and adolescents. The objective of the current study was to carry out the cross-cultural adaptation of CPQ_11–14 for the Brazilian Portuguese language.

Methods

After translation and cross-cultural adaptation, the CPQ _11–14 was tested on 160 11-to-14-year-old children who were clinically and radiographically examined for the presence or absence of dental caries. The children were receiving dental care at the Pediatric Dental and Orthodontic clinics of the Federal University of Minas Gerais, Brazil. To test the quality of the translation, 17 children answered the questionnaire. The internal consistency of the instrument was assessed by Cronbach's Alpha Coefficient and the test-retest reliability by Intraclass Correlation Coefficient (ICC).

Results

The mean CPQ_11–14 score were 24.5 [standard deviation (SD) 18.27] in the group with caries and 12.89 [SD 10.95] in the group without caries. Median scores were 20 and 10 in the groups with and without caries, respectively (p < 0.001). Significant associations were identified between caries status and all CPQ domains (p < 0.05). Internal reliability was confirmed by a Cronbach's alpha coefficient of 0.86. Test-retest reliability revealed satisfactory reproducibility (ICC = 0.85). The questionnaire proved to be a valid instrument. Construct validity was satisfactory, demonstrating highly significant correlations with global indicators for the total scale and subscales. The CPQ_11–14 score was able to discriminate between different oral conditions (groups without and with untreated caries).

Conclusion

The present study demonstrated that the CPQ_11–14 is applicable to children in Brazil. It has satisfactory psychometric properties, but further research is required to evaluate these properties in a population study.

Examining the hierarchical factor structure of the SF-36 Taiwan version by exploratory and confirmatory factor analysis

RATIONALE

The purpose of this study was to examine the factor structure of the Medical Outcome Study Short Form-36 Taiwan version (SF-36 Taiwan version) using data from the 2001 National Health Interview Survey in Taiwan.

METHOD

The 2001 National Health Interview Survey was conducted by stratified multistage systematic sampling, resulting in 19,777 valid responses for the SF-36 Taiwan version. In this study, the 19,777 participants were randomly divided into two independent samples. One sample (n = 9856) was used for exploratory factor analysis (EFA), and the other (n = 9921) was used for confirmatory factor analysis (CFA).

RESULTS

The EFA suggested a seven-first-order-factor structure for the SF-36 Taiwan version. In addition, hierarchical EFA revealed that there was only one second-order factor underlying the seven first-order factors. Further, CFA was conducted on the other sample to compare the performances of the original model with eight first-order factors and two second-order factors, and the revised model with seven first-order factors and one second-order factor. The CFA results revealed that the original model was better than the revised model.

CONCLUSION

According to the EFA and CFA, it can be concluded that the original structure is still acceptable for the SF-36 Taiwan version.

[IFCT-0302 trial: randomised study comparing two follow-up schedules in completely resected non-small cell lung cancer]

BACKGROUND

The authorities advocate a minimalist attitude towards the follow-up of resected bronchial carcinoma (clinical examination and chest x-ray). A survey showed that 70% of French respiratory physicians have chosen to use the CT scanner and often endoscopy. The published data are equivocal and are often based on retrospective studies. Lung cancer is a good model for a study of post-operative surveillance. Recurrences often occur in easily observed areas, they may be detected while still asymptomatic and are sometimes potentially curable. Second primary tumours may develop at the same site.

METHODS

The Intergroupe Francophone de Cancerologie Thoracique (IFCT) has initiated a trial comparing simple follow-up (clinical examination, chest x-ray) with a more intensive follow-up (CT scan, fibreoptic bronchoscopy). The surveillance will take place every 6 months for 2 years and then annually until 5 years.

EXPECTED RESULTS

The main aim is to determine whether intensive follow-up improves patient survival. The opposite question is equally important. If an expensive and demanding follow-up does not affect the chances of cure these results will influence our practice.

Methods and representativeness of a European survey in children and adolescents: the KIDSCREEN study

BACKGROUND

The objective of the present study was to compare three different sampling and questionnaire administration methods used in the international KIDSCREEN study in terms of participation, response rates, and external validity.

METHODS

Children and adolescents aged 8-18 years were surveyed in 13 European countries using either telephone sampling and mail administration, random sampling of school listings followed by classroom or mail administration, or multistage random sampling of communities and households with self-administration of the survey materials at home. Cooperation, completion, and response rates were compared across countries and survey methods. Data on non-respondents was collected in 8 countries. The population fraction (PF, respondents in each sex-age, or educational level category, divided by the population in the same category from Eurostat census data) and population fraction ratio (PFR, ratio of PF) and their corresponding 95% confidence intervals were used to analyze differences by country between the KIDSCREEN samples and a reference Eurostat population.

RESULTS

Response rates by country ranged from 18.9% to 91.2%. Response rates were highest in the school-based surveys (69.0%-91.2%). Sample proportions by age and gender were similar to the reference Eurostat population in most countries, although boys and adolescents were slightly underrepresented (PFR <1). Parents in lower educational categories were less likely to participate (PFR <1 in 5 countries). Parents in higher educational categories were overrepresented when the school and household sampling strategies were used (PFR = 1.78-2.97).

CONCLUSION

School-based sampling achieved the highest overall response rates but also produced slightly more biased samples than the other methods. The results suggest that the samples were sufficiently representative to provide reference population values for the KIDSCREEN instrument.

Impact of late-onset Pompe disease on participation in daily life activities: Evaluation of the Rotterdam Handicap Scale

With the recent approval of enzyme replacement therapy for Pompe disease, insight into the social consequences of this disorder becomes even more relevant. The aim of this study was to measure the impact of late-onset Pompe disease on participation in daily life activities and to evaluate the applicability of the Rotterdam Handicap Scale (RHS) for use in Pompe disease. Two hundred fifty-seven adult patients from different countries participated in the study. The mean RHS score was 25.9+/-6.5 on a scale of 9-36. Individual item scores were lowest for 'domestic tasks indoors', 'domestic tasks outdoors', and 'work/study'. The mean RHS score differed significantly between patients with and without respiratory support (22.9 vs. 28.5, p<0.001) and patients with and without a wheelchair (20.9 vs. 29.5, p<0.001). No differences in RHS score were found between countries. The RHS showed good internal consistency and excellent Test-retest reliability. A ceiling effect of 8% was present. We conclude that the RHS seems suitable for this patient population and that Pompe disease has a large impact on the participation in daily life activities, in particular on the ability of patients to fulfil their work or study.

Comparison of quality of life scores among non-exercising adolescent females and adolescent dancers with oligomenorrhea and amenorrhea

STUDY OBJECTIVE

To evaluate whether oligomenorrhea and amenorrhea in adolescent females would have a negative effect on the standard quality of life (QOL) scores as compared to eumenorrheic adolescents, and whether such scoring would differ between those with exercise related oligo/amenorrhea or those with hypothalamic/ovarian causes.

DESIGN

Prospective cross-sectional observational survey.

METHODS

Young dancers were recruited from the Sports Clinic of a collegial School of Dance, and non-dancers were recruited from a hospital-based adolescent gynecology clinic. All subjects completed a structured self-answering questionnaire recording epidemiological data and a 36-item Short Form Health Survey (SF-36). All subjects had a full hormonal profile and pelvic ultrasound to study ovarian morphology.

RESULTS

Sixty-six dancers (19 with exercise-related oligo/amenorrhea and 47 eumenorrhoeic) and 90 non-dancers (45 eumenorrhoeic and 45 oligo/amenorrheic) were analyzed, all 16-20 years of age. There was no difference in the scoring between eumenorrheic dancers and non-dancers. Oligo/amenorrheic dancers did not score lower than eumenorrheic dancers. Compared with eumenorrheic subjects or to oligo/amenorrheic dancers, oligo/amenorrheic non-dancers had significantly lower QOL scores in the domains of physical functioning (PF) and general health (GH) and vitality (VT).

CONCLUSION

Compared with eumenorrheic adolescents, QOL scores were lower in non-exercising adolescents with oligo-amenorrhea, but not those with exercise related oligo/amenorrhea. The negative effects of oligomenorrhea and amenorrhea on quality of life were apparently attenuated if the menstrual dysfunction was related to physical training.

Translation and cultural adaptation of a mental health outcome measure: the BASIS-R(c)

Culturally and linguistically appropriate outcome measures are needed to address the needs of Latino consumers of mental health services. The revised Behavior and Symptom Identification Scale (BASIS-R(c)) is an English-language consumer self-report measure designed to assess outcome of behavioral health or substance abuse treatment. This study sought to develop a culturally and linguistically appropriate version of the BASIS-R(c) for Spanish-speaking Latinos. To achieve this goal, the English instrument was translated and adapted into Spanish by an international bilingual committee and tested in four focus groups and 45 cognitive interviews with Puerto Ricans, Dominicans, and Mexicans living in the United States and Puerto Rico. Focus groups and cognitive interviews provided qualitative and quantitative information about the instrument's content and format, and respondents' understanding of the instructions, questionnaire items, time frame, and response options. Respondents' ratings of the clarity and importance of each item were also obtained. Analyses of focus group and cognitive interview data identified items that were confusing or difficult for participants. Findings suggest that the Spanish version of the BASIS-R(c) incorporated the cultural diversity of the three groups of Latinos in this study without compromising the validity of the English version of the BASIS.

The SF36 Version 2: critical analyses of population weights, scoring algorithms and population norms

BACKGROUND

The SF36 Version 2 (SF36V2) is a revision of the SF36 Version 1, and is a widely used health status measure. It is important that guidelines for interpreting scores are available.

METHOD

A population sample of Australians (n = 3015) weighted to achieve representativeness was administered the SF36V2. Comparisons between published US weights and sample derived weights were made, and Australian population norms computed and presented.

MAJOR FINDINGS

Significant differences were observed on 7/8 scales and on the mental health summary scale. Possible causes of these findings may include different sampling and data collection procedures, demographic characteristics, differences in data collection time (1998 vs. 2004), differences in health status or differences in cultural perception of the meaning of health. Australian population norms by age cohort, gender and health status are reported by T-score as recommended by the instrument developers. Additionally, the proportions of cases within T-score deciles are presented and show there are important data distribution issues.

PRINCIPAL CONCLUSIONS

The procedures reported here may be used by other researchers where local effects are suspected. The population norms presented may be of interest. There are statistical artefacts associated with T-scores that have implications for how SF36V2 data are analysed and interpreted.

Medical disorders affect health outcome and general functioning depending on comorbid major depression in the general population

OBJECTIVE

The objective of this study was to compare health-related quality of life (HR-QoL), disability/work productivity, and health care utilization in a variety of medical disorders with and without comorbid major depressive disorder (MDD) in the general population.

METHODS

Twelve-month MDD (Composite International Diagnostic Interview) diagnosis was determined among 4181 participants from a community sample. Medical diagnoses (respiratory, cardiovascular, allergic, endocrine/metabolic, gastrointestinal, and neurological diseases) were made after medical examination. HR-QoL was evaluated with the MOS-SF-36. Outpatient doctor visits and disability/work productivity were assessed by self-report.

RESULTS

Comorbid MDD was associated with a lower SF-36 mental summary score in all medical diagnoses and with a lower physical summary score in comorbid allergic and neurological disorders. The number of coexisting medical disorders was strongly related to lower physical and mental summary scores in cases without comorbid depression. The number of outpatient doctor visits increased by 42% when any of the medical disorders without comorbid MDD was present, and comorbid MDD was associated with a further 24-42% increase, depending on the medical disorder. Comorbid MDD was strongly associated with lower full-time working status (37.1% with MDD vs. 51.0% without MDD) and with a significant increase in disability days (45%) in the presence of any medical disorder.

CONCLUSIONS

Findings have consequences for diagnostic and treatment procedures, as well as in relation to the importance of the number of medical disorders in future studies.

Normative data and discriminative properties of short form 36 (SF-36) in Turkish urban population

Background

SF-36 has been both translated into different languages and adapted to different cultures to obtain comparable data on health status internationally. However there have been only a limited number of studies focused on the discriminative ability of SF-36 regarding social and disease status in developing countries. The aim of this study was to obtain population norms of the short form 36 (SF-36) health survey and the association of SF-36 domains with demographic and socioeconomic variables in an urban population in Turkey.

Methods

A cross-sectional study. Face to face interviews were carried out with a sample of households. The sample was systematically selected from two urban Health Districts in Izmir, Turkey. The study group consisted of 1,279 people selected from a study population of 46,290 people aged 18 and over.

Results

Internal consistencies of the scales were high, with the exception of mental health and vitality. Physical health scales were associated with both age and gender. On the other hand, mental health scales were less strongly associated with age and gender. Women reported poorer health compared to men in general. Social risk factors (employment status, lower education and economic strain) were associated with worse health profiles. The SF-36 was found to be capable of discriminating disease status.

Conclusion

Our findings, cautiously generalisable to urban population, suggest that the SF-36 can be a valuable tool for studies on health outcomes in Turkish population. SF-36 may also be a promising measure for research on health inequalities in Turkey and other developing countries.

The use of focus groups in the development of the KIDSCREEN HRQL questionnaire

There is increasing interest in the public health sector in the health-related quality of life (HRQL) of healthy children. However, most HRQL instruments are developed for children with a chronic illness. In addition, existing questionnaires are mostly based on expert opinion about what constitutes HRQL and the opinions and views of healthy children are seldom included. In the European project KIDSCREEN, a generic questionnaire was developed for children between the ages of 8 and 18 on the basis of children's opinions about what constitutes HRQL. Focus group discussions were organised in six European countries to explore the HRQL as perceived by children. There were six groups in each country, stratified by gender and age. The age groups were 8-9 years, 12-13 years, and 16-17 years, with 4-8 children in each group. Experienced moderators guided the discussions. The full discussions were audiotaped, transcribed and content-analysed. The discussions went smoothly, with much lively debate. For the youngest group, the most important aspect of their HRQL was family functioning. For both younger and older adolescents, social functioning, including the relationship with peers, was most important. Children in all groups considered physical and cognitive functioning to be less important than social functioning. These key findings were taken into account when designing the KIDSCREEN HRQL questionnaire for healthy children and adolescents, with more emphasis being placed on drawing up valid scales for family and social functioning. In addition, items were constructed using the language and lay-out preferred by the youngsters themselves. We conclude that focus groups are a useful way of exploring children's views of HRQL, showing that an emphasis should be placed on constructing valid social and family scales.

Spanish cross-cultural adaptation and validation of the National Institutes of Health Stroke Scale

OBJECTIVES

To adapt and validate a Spanish-language version (SV) of the National Institutes of Health Stroke Scale (NIHSS) to facilitate its use in Spanish-speaking contexts.

PATIENTS AND METHODS

The methods recommended by the International Quality of Life Assessment Project were followed. Two forward translations and 1 back translation of the NIHSS were developed to ensure lingual and cultural equivalence. A final revised SV-NIHSS was administered by 8 physicians to patients with stroke in 3 clinics in Buenos Aires, Argentina, from September 2003 to December 2003.

RESULTS

The study included 102 patients (mean +/- SD age, 73.3+/-6.5 years; 56% women) with stroke (86% ischemic). The SV-NIHSS mean baseline score was 9.78+/-7.04. Interrater reliability was Independently evaluated for 98 patients, showing a high agreement: kappa, 0.77 to 0.99 for the 15 items; interrater correlation coefficient, 0.991 (95% confidence Interval, 0.987-0.994). Intrarater reliability was excellent: kappa, 0.86 to 1.00 for the 15 items; mean intrarater correlation coefficient, 0.994 (95% confidence interval, 0.991-0.996). Construct validity was also adequate; the SV-NIHSS had a negative correlation with baseline Glasgow Coma Scale (Spearman coefficient = -0.574, P < .001) and with Barthel index at 3 months (Spearman coefficient = -0.658, P < .001). Patients with different Rankin scores at 3 months also had significantly different baseline SV-NIHSS scores, from a mean of 4.29+/-2.21 for Rankin score of 0 to a mean of 29.40+/-3.97 for Rankin score of 6 (P < .001).

CONCLUSION

This study shows that a Spanish-language version of the NIHSS developed with internationally recommended methods is reliable and valid when applied in a Spanish-speaking setting.

Evaluation of the Turkish version of the Bath Ankylosing Spondylitis Patient Global Score (BAS-G)

The objective of this study was to investigate the reliability and validity of the Turkish version of the Bath Ankylosing Spondylitis (AS) Patient Global Score (BAS-G). Seventy-one consecutive patients with AS were enrolled into the study. Patients were requested to fill in the questionnaire on the day of admission (first visit), on a second occasion within 24 h after admission (second visit) for test-retest reliability analysis, and on a third occasion for assessing sensitivity to change. Construct validity was assessed by correlation analysis with the Bath AS Functional Index (BASFI), Dougados Functional Index (DFI), Dougados Articular Index (DAI), physical examination findings, and several other parameters. Test-retest reliability analysis of individual BAS-G scores at initial and second visits showed good intraclass correlations [n=46, intraclass correlation=0.928 (0.870-0.960) and intraclass correlation=0.853 (0.725-0.920), for 1-week and 6-month scores, respectively]. Both 1-week and 6-month scores showed moderate correlations with the BASFI (r=0.586 and r=0.503, respectively, P=0.000 for both). The 1-week score also showed moderate correlation with the DFI (r=0.530, P=0.000). The 1-week score showed weak correlations with finger-to-floor distance (r=0.263, P=0.027), chest expansion (r=-0.245, P=0.039), and DAI (r=0.271, P=0.036). Change in the 1-week score at the third visit showed good correlation with the BASFI score (r=0.670, P=0.000, n=36) and moderate correlation with the DFI (r=0.440, P=0.017, n=29). The Turkish version of the BAS-G has good reliability and validity. It is a good tool for assessing patients with AS or other rheumatic diseases in clinical practice and research.

Determining the basic psychometric properties of the Greek KDQOL-SF

The aim of this study was to determine the basic psychometric properties, i.e. reliability and validity, of the Greek version of the Kidney Disease Quality of Life Short Form (KDQOL-SF). The instrument was self-administered to a homogenous group of 665 end stage renal disease patients in 20 dialysis units throughout Greece and the overall response rate was 72.6%. Reliability was demonstrated by Cronbach's alpha exceeding the recommended minimum value of 0.70 in all, except one, scales. Tests of item-internal consistency, after correction for overlap, resulted in correlations between items and their hypothesized scales, which exceeded the 0.40 standard in 94.5% of the cases. Item discriminant validity tests indicated 100% scaling success for six out of eight generic and disease-targeted scales. Validity was supported by the confirmation of expected correlations between scales and the overall health-rating item included in the instrument and with sociodemographic and self-reported health variables. Multiple stepwise linear regression analysis demonstrated that all disease-targeted scales were important predictors of SF-36 general health scales and the variance explained ranged from 37% to 57%. Overall, the psychometric properties of the KDQOL-SF, resulting from this first-time administration of the instrument to a Greek dialysis population, were good and the disease targeted scales were informative and of high internal consistency reliability. Cross-sectional construct validity is demonstrated, despite the lack of external validity criteria based on clinical ratings of severity. The results support administering the Greek KDQOL-SF in studies evaluating dialysis therapy and contribute to transnational comparison of findings.

A comparative review of health-related quality-of-life measures for use in HIV/AIDS clinical trials

With the advent of highly active antiretroviral therapy (HAART), HIV-infected patients are living longer and are concerned not only with a treatment's ability to extend their life but also with the quality of the life they are able to lead. Regulatory authorities are also paying closer attention to the use of health-related quality-of-life (HR-QOL) measures in clinical trials and to the subsequent claims that are made based on the results. This paper reviews existing HR-QOL measures reported in the HIV/AIDS literature since 1990 and identifies those most worthy of consideration for use in future clinical trials.A comprehensive review following predefined selection criteria was conducted. Generic and HIV-targeted measures were assessed for content and practicality for the clinical trial setting. The generic measures were additionally reviewed for the ability to produce preference-based index scores and for the existence of normative general population data. Three generic and six HIV-targeted measures met these selection criteria and were then assessed more fully in terms of their development (HIV-targeted measures), psychometric properties and appropriateness for use in clinical trials.It was determined that each of the selected generic measures (i.e. Medical Outcomes Study [MOS] 36-Item Short Form Survey Instrument [SF-36], EQ-5D, Health Utilities Index [HUI]) could serve as a useful adjunct to an HIV-targeted measure in a trial. The Functional Assessment of HIV Infection (FAHI) and MOS-HIV health survey were deemed the two most appropriate HIV-targeted measures. Each of the measures can be self-administered in < or = 10 minutes and there was ample evidence of their excellent psychometric properties. However, they would not be optimal in all HIV-infected subgroups (e.g. treatment naive vs advanced; adolescents vs older adults) targeted for clinical trial interventions. Although there is no one best HR-QOL measure for use in HIV/AIDS clinical trials, based on our review criteria we identified three generic and two HIV-targeted candidate measures. However, these measures have their limitations and it is clear that greater consensus needs to develop regarding more effective and efficient approaches to HR-QOL measurement in HIV/AIDS clinical trials. Along with the increasingly complex HR-QOL measurement task resulting from changes in the HIV-infected population and shifts in the HR-QOL burden associated with HIV infection and its treatment over the past 25 years, it is increasingly important that HR-QOL outcomes become viable endpoints in HIV/AIDS clinical trials.

A systematic review: how to choose appropriate health-related quality of life (HRQOL) measures in routine general practice?

In more recent times, health-related quality of life (HRQOL) measurements have formed an important part of assessing the quality of routine care in general practice. For a measure to have clinical usefulness it must not only be valid, appropriate, reliable, responsive, and capable of being interpreted, but it must also be simple, fast to complete, easy to score, and provide useful clinical data. The Two-step method of choosing appropriate measures is introduced. Then through comparison of generic instruments with disease-specific instruments, we can conclude that sometimes a combination of generic and disease-specific HRQOL measures may be more appropriate for monitoring changes in a patient's health status due to an intervention.

Construct Validation of the Greek SF-36 Health Survey

OBJECTIVE

To test the construct validity of the Short-Form 36 (SF-36) Health Survey, using structural equation modeling (SEM).

METHODS

Cross-sectional survey was conducted. Data were collected from 1007 participants in a stratified sample of adult general population, interviewed face-to-face by trained interviewers.

RESULTS

SEM analyses supported the superiority of the eight first-order factor model of health. Higher-order analyses suggested that a model with three correlated second-order factors (physical health, general well-being, general mental health) and one third-order factor (health) provided a satisfactory fit to the data.

CONCLUSIONS

These results confirm the multidimensional structure of the SF-36 and underscore the feasibility of multinational comparisons of health status using this instrument. They also support the use of eight subscale scores in parallel with three second-order summary scores rather than one overall score.

Are factor analytical techniques used appropriately in the validation of health status questionnaires? A systematic review on the quality of factor analysis of the SF-36

Factor analysis is widely used to evaluate whether questionnaire items can be grouped into clusters representing different dimensions of the construct under study. This review focuses on the appropriate use of factor analysis. The Medical Outcomes Study Short Form-36 (SF-36) is used as an example. Articles were systematically searched and assessed according to a number of criteria for appropriate use and reporting. Twenty-eight studies were identified: exploratory factor analysis was performed in 22 studies, confirmatory factor analysis was performed in five studies and in one study both were performed. Substantial shortcomings were found in the reporting and justification of the methods applied. In 15 of the 23 studies in which exploratory factor analysis was performed, confirmatory factor analysis would have been more appropriate. Cross-validation was rarely performed. Presentation of the results and conclusions was often incomplete. Some of our results are specific for the SF-36, but the finding that both the application and the reporting of factor analysis leaves much room for improvement probably applies to other health status questionnaires as well. Optimal reporting and justification of methods is crucial for correct interpretation of the results and verification of the conclusions. Our list of criteria may be useful for journal editors, reviewers and researchers who have to assess publications in which factor analysis is applied.

The Short Form Health Survey (SF-36): translation and validation study of the Iranian version

This was a large population-based study to develop and validate the Iranian version of the Short Form Health Survey (SF-36) for use in health related quality of life assessment in Iran. A culturally comparable questionnaire was developed and pilot tested. Then, the Iranian version of the SF-36 was administered to a random sample of 4163 healthy individuals aged 15 years and over in Tehran. The mean age of the respondents was 35.1 (SD = 16.0) years, 52% were female, mostly married (58%) and the mean years of their formal education was 10.0 (SD = 4.5). Reliability was estimated using the internal consistency and validity was assessed using known groups comparison and convergent validity. In addition factor analysis was performed. The internal consistency (to test reliability) showed that all eight SF-36 scales met the minimum reliability standard, the Cronbach's alpha coefficients ranging from 0.77 to 0.90 with the exception of the vitality scale (alpha = 0.65). Known groups comparison showed that in all scales the SF-36 discriminated between men and women, and old and the young respondents as anticipated (all p values less than 0.05). Convergent validity (to test scaling assumptions) using each item correlation with its hypothesized scale showed satisfactory results (all correlation above 0.40 ranging from 0.58 to 0.95). Factor analysis identified two principal components that jointly accounted for 65.9% of the variance. In general, the Iranian version of the SF-36 performed well and the findings suggest that it is a reliable and valid measure of health related quality of life among the general population.

Comparative study of two Japanese rhinoconjunctivitis quality-of-life questionnaires

CONCLUSION

Two questionnaires were used to assess quality of life (QOL) in allergic rhinitis: the Japanese translation of the Rhino-conjunctivitis Quality of Life Questionnaire (RQLQJ) and an original Japanese QOL questionnaire (JRQLQ). Either questionnaire may be used to assess QOL depending on differences in target domains.

OBJECTIVES

Although pollinosis is a common disease which has a major impact on patient QOL, no internationally standardized questionnaire has been available in Japan until now. The aim of this study was to compare two currently available QOL questionnaires for allergic rhinitis in Japan-the RQLQJ and JRQLQ-in terms of their appropriateness for clinical use and their psychometric properties.

MATERIAL AND METHODS

A multicenter, inter-group, cross-sectional study was conducted in 187 adult symptomatic patients with Japanese cedar pollinosis in 2003. Patient scores on the two questionnaires were compared in terms of both overall and comparable domains. We also examined the acceptability, construct and reliability of both questionnaires.

RESULTS

The questionnaires were highly correlated in terms of both overall and comparable domain scores. In addition, both questionnaires had equal and satisfactory psychometric validity, demonstrating that they are both useful tools for assessing QOL in rhinitis. However, when compared with each other, the JRQLQ focuses mainly on activities of daily life and is simpler, while the RQLQJ focuses mainly on rhinitis-related health and is more responsive.

Is the standard SF-12 health survey valid and equivalent for a Chinese population?

INTRODUCTION

Chinese is the world's largest ethnic group but few health-related quality of life (HRQoL) measures have been tested on them. The aim of this study was to determine if the standard SF-12 was valid and equivalent for a Chinese population.

METHODS

The SF-36 data of 2410 Chinese adults randomly selected from the general population of Hong Kong (HK) were analysed. The Chinese (HK) specific SF-12 items and scoring algorithm were derived from the HK Chinese population data by multiple regressions. The SF-36 PCS and MCS scores were used as criteria to assess the content and criterion validity of the SF-12. The standard and Chinese (HK) specific SF-12 PCS and MCS scores were compared for equivalence.

RESULTS

The standard SF-12 explained 82% and 89% of the variance of the SF-36 PCS and MCS scores, respectively, and the effect size differences between the standard SF-36 and SF-12 scores were less than 0.3. Six of the Chinese (HK) specific SF-12 items were different from those of the standard SF-12, but the effect size differences between the Chinese (HK) specific and standard SF-12 scores were mostly less than 0.3.

CONCLUSIONS

The standard SF-12 was valid and equivalent for the Chinese, which would enable more Chinese to be included in clinical trials that measure HRQoL.

Validating and norming of the Greek SF-36 Health Survey

The main objective of this study was to validate the Greek SF-36 Health Survey and to provide general population normative data. The survey was administered to a stratified representative sample (n = 1426) of the general population residing in the broader Athens area and the response rate was 70.6%. Statistical analysis, according to documented procedures developed within the IQOLA Project, was performed. The missing value rate was very low, ranging from 0.1 to 1.3% at the item level. Multitrait scaling analysis confirmed the hypothesized scale structure of the SF-36. Cronbach's alpha coefficient met the criterion (>0.70) for group analysis in all eight scales. Known group comparisons yielded consistent support of construct validity of the SF-36. Significant statistical differences in mean scores were observed in relation to demographic and social characteristics such as gender, age, education and marital status.

Quality of life measures for fecal incontinence and their use in children

BACKGROUND

Fecal incontinence is a common problem within society from childhood through to the elderly. Its clinical assessment has focussed on severity and frequency of soiling episodes but it is increasingly recognized to have an impact on physical, psychological and social well-being (quality of life [QOL]). This is likely to be particularly important in childhood. The aim of the present study was to critically evaluate the development and application of disease-specific QOL measures, focusing particularly on their use in children.

METHODS

Generally recognized disease-specific QOL measures for fecal incontinence were identified and their generation and validation were critically evaluated.

RESULTS

Six instruments were identified: Ditesheim and Templeton QOL Scoring System, Manchester Health Questionnaire, Hirschsprung's Disease/Anorectal Malformation Quality of Life Questionnaire (HAQL), Gastrointestinal Quality of Life Index (GIQLI), Fecal Incontinence TyPE Specification, and the Fecal Incontinence Quality of Life Scale (FIQL). Although the FIQL appeared to be the better tool for adults with fecal incontinence because it was brief and had the best validity and reliability, it needed further modification to become appropriate for use in children. In particular, items relating to sexual activity were inappropriate.

CONCLUSION

Neither the FIQL nor other disease-specific instruments met basic psychometric standards for use in children with fecal incontinence. Substantial revision of currently available instruments will be required to meet the needs of this population.

The Short-Form Headache Impact Test (HIT-6) was psychometrically equivalent in nine languages

BACKGROUND AND OBJECTIVE

This study examined the psychometric properties and equivalence of the six-item Headache Impact Test (HIT-6) across 11 languages in 14 countries.

METHODS

A multicenter, international cross-sectional study conducted in a primary care setting. Data obtained from 1,171 adults from 14 countries who consulted their primary care physician for headache completed the HIT-6 questionnaire and a headache survey were included in this analysis. Item-level statistics (e.g., range of response choices used by participants), item-scale statistics (e.g., item-total correlations), scale level statistics (e.g., internal consistency reliability), and tests of differential item functioning were conducted to examine the psychometric properties of all HIT-6 translations and their comparability across translations.

RESULTS

Across languages, missing data were low, item-scale correlations were high, reliability was adequate, and item-level statistics were generally comparable. We found only minor differential item functioning, suggesting that the HIT-6 translations are equivalent to the U.S. English form.

CONCLUSIONS

Psychometric analyses indicate that most HIT-6 translations (Canadian English, French, Greek, Hungarian, UK English, Hebrew, Portuguese, German, Spanish, and Dutch) are comparable to U.S. English. Improvements may be needed in the Finnish and Slovakian translations and the appropriateness of using the HIT-6 in South Africa should be explored further.

The validity of the SF-36 in an Australian National Household Survey: demonstrating the applicability of the Household Income and Labour Dynamics in Australia (HILDA) Survey to examination of health inequalities

BACKGROUND

The SF-36 is one of the most widely used self-completion measures of health status. The inclusion of the SF-36 in the first Australian national household panel survey, the Household, Income and Labour Dynamics in Australia (HILDA) Survey, provides an opportunity to investigate health inequalities. In this analysis we establish the psychometric properties and criterion validity of the SF-36 HILDA Survey data and examine scale profiles across a range of measures of socio-economic circumstance.

METHODS

Data from 13,055 respondents who completed the first wave of the HILDA Survey were analysed to determine the psychometric properties of the SF-36 and the relationship of the SF-36 scales to other measures of health, disability, social functioning and demographic characteristics.

RESULTS

Results of principle components analysis were similar to previous Australian and international reports. Survey scales demonstrated convergent and divergent validity, and different markers of social status demonstrated unique patterns of outcomes across the scales.

CONCLUSION

Results demonstrated the validity of the SF-36 data collected during the first wave of the HILDA Survey and support its use in research examining health inequalities and population health characteristics in Australia.

The validity of the SF-36 in an Australian National Household Survey: demonstrating the applicability of the Household Income and Labour Dynamics in Australia (HILDA) Survey to examination of health inequalities

Background

The SF-36 is one of the most widely used self-completion measures of health status. The inclusion of the SF-36 in the first Australian national household panel survey, the Household, Income and Labour Dynamics in Australia (HILDA) Survey, provides an opportunity to investigate health inequalities. In this analysis we establish the psychometric properties and criterion validity of the SF-36 HILDA Survey data and examine scale profiles across a range of measures of socio-economic circumstance.

Methods

Data from 13,055 respondents who completed the first wave of the HILDA Survey were analysed to determine the psychometric properties of the SF-36 and the relationship of the SF-36 scales to other measures of health, disability, social functioning and demographic characteristics.

Results

Results of principle components analysis were similar to previous Australian and international reports. Survey scales demonstrated convergent and divergent validity, and different markers of social status demonstrated unique patterns of outcomes across the scales.

Conclusion

Results demonstrated the validity of the SF-36 data collected during the first wave of the HILDA Survey and support its use in research examining health inequalities and population health characteristics in Australia.

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.

Health-related quality of life associated with chronic conditions in eight countries: results from the International Quality of Life Assessment (IQOLA) Project

CONTEXT

Few studies and no international comparisons have examined the impact of multiple chronic conditions on populations using a comprehensive health-related quality of life (HRQL) questionnaire.

OBJECTIVE

The impact of common chronic conditions on HRQL among the general populations of eight countries was assessed.

DESIGN

Cross-sectional mail and interview surveys were conducted.

PARTICIPANTS AND SETTING

Sample representatives of the adult general population of eight countries (Denmark, France, Germany, Italy, Japan, The Netherlands, Norway and the United States) were evaluated. Sample sizes ranged from 2031 to 4084.

MAIN OUTCOME MEASURES

Self-reported prevalence of chronic conditions (including allergies, arthritis, congestive heart failure, chronic lung disease, hypertension, diabetes, and ischemic heart disease), sociodemographic data and the SF-36 Health Survey were obtained. The SF-36 scale and summary scores were estimated for individuals with and without selected chronic conditions and compared across countries using multivariate linear regression analyses. Adjustments were made for age, gender, marital status, education and the mode of SF-36 administration.

RESULTS

More than half (55.1%) of the pooled sample reported at least one chronic condition, and 30.2% had more than one. Hypertension, allergies and arthritis were the most frequently reported conditions. The effect of ischemic heart disease on many of the physical health scales was noteworthy, as was the impact of diabetes on general health, or arthritis on bodily pain scale scores. Arthritis, chronic lung disease and congestive heart failure were the conditions with a higher impact on SF-36 physical summary score, whereas for hypertension and allergies, HRQL impact was low (comparing with a typical person without chronic conditions, deviation scores were around -4 points for the first group and -1 for the second). Differences between chronic conditions in terms of their impact on SF-36 mental summary score were low (deviation scores ranged between -1 and -2).

CONCLUSIONS

Arthritis has the highest HRQL impact in the general population of the countries studied due to the combination of a high deviation score on physical scales and a high frequency. Impact of chronic conditions on HRQL was similar roughly across countries, despite important variation in prevalence. The use of HRQL measures such as the SF-36 should be useful to better characterize the global burden of disease.

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.

Quality of life in rural and urban populations in Lebanon using SF-36 health survey

BACKGROUND

Measuring health status in a population is important for the evaluation of interventions and the prediction of health and social care needs. Quality of life (QoL) studies are an essential complement to medical evaluation but most of the tools available in this area are in English. In order to evaluated QoL in rural and urban areas in Lebanon, the short form 36 health survey (SF-36) was adapted into Arabic.

METHODS

SF-36 was administered in a cross-sectional study, to collect sociodemographic and environmental variables as well as self reported morbidity. We analysed a representative sample containing 1632 subjects, from whom we randomly picked 524 subjects aged 14 years and over. The translation, cultural adaptation and validation of the SF-36 followed the International Quality of Life Assessment methodology. Multivariate analysis (generalized linear model) was performed to test the effect of habitat (rural on urban areas) on all domains of the SF-36.

RESULTS

The rate of missing data is very low (0.23% of items). Item level validation supported the assumptions underlying Likert scoring. SF-36 scale scores showed wide variability and acceptable internal consistency (Cronbach's alpha >0.70), factor analysis yielded patterns of factor correlation comparable to that found in the U.S.A and France. Patients resident in rural areas had higher vitality scores than those in urban areas. Older people reported more satisfaction with some domains of life than younger people, except for physical functioning. The QoL of women is poorer than men; certain symptoms and morbidity independently influence the domains of SF-36 in this population.

CONCLUSION

The results support the validity of the SF-36 Arabic version. Habitat has a minor influence on QoL, women had a poor QoL, and health problems had differential impact on QoL.

The Italian version of the 25-item National Eye Institute Visual Function Questionnaire: translation, validity, and reliability

OBJECTIVE

To test the Italian adaptation of the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ 25) and to investigate its validity and reliability.

METHODS

This prospective observational study enrolled nonhospitalized patients with 1 of 5 chronic eye diseases, and a reference sample of subjects without eye diseases. Eligible participants had to be cognitively able to respond to a health status interview and be affected by 1 of the following eye conditions: senile cataract, age-related macular degeneration, glaucoma, diabetic retinopathy, and cytomegalovirus retinitis or low vision. A control group was composed of subjects with no evidence of underlying eye diseases. The Italian self-administered versions of Medical Outcomes Study Short Form and of the NEI-VFQ 25 were administered to all participants. Reliability and validity of the Italian translation of the NEI-VFQ 25 were tested using statistical methods.

RESULTS

Statistical analysis points out that the Italian version of the NEI-VFQ 25 has good validity, discriminatory power, internal consistency, and reliability.

CONCLUSIONS

This Italian version of the NEI-VFQ 25 shows psychometric properties comparable to those of the American version, and thus can be used in clinical research as a specific measure of quality of life in patients with chronic eye diseases.

[Reference population values for the Spanish Child Health and Illness Profile-Adolescent Edition (CHIP-AE) using a representative school-based sample]

AIM

The Child Health and Illness Profile (CHIP-AE) is a generic health status instrument for adolescents aged 12-19 years adapted for use in Spain. The aim of this study was to obtain reference population values of the Spanish version of the CHIP-AE.

METHODS

The CHIP-AE was administered to a representative sample of adolescents from schools in Barcelona. The sample was selected by using cluster-sampling, stratified by type of school (public or private) and an ecological socioeconomic index (Indice de Capacidad Familiar: low, middle, and high). The CHIP-AE scores were standardized to a mean of 20 and a standard deviation (SD) of 5. Means and percentiles were computed. Means were compared by age, gender, and socioeconomic status using analysis of variance.

RESULTS

The response rate was 81% (n = 902). The distribution of the CHIP-AE scores presented a wide range with scores generally skewed toward positive health status. Nevertheless, the results suggest that the sample selected from a general population was not free of health problems. Twenty-five percent of adolescents presented scores below 17.2 in the domain of discomfort, indicating an effect size of 0.56 standardized SD units. The distribution of scores in the reference samples from Barcelona was similar to the original results in Baltimore (USA), with some marginal differences in individual risks.

CONCLUSIONS

The CHIP-AE systematically gathers information on health domains in adolescents. The results from this reference sample will allow comparisons with adolescents from other regions, and/or with different health problems, as well as description of inequalities in health during adolescence.

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.

Comparing health inequalities among men aged 18-65 years in Australia and England using the SF-36

OBJECTIVE

To compare the distribution of the domains and summary scores of the SF-36 health survey by occupation-related social classes in England and Australia for employed males age 18-65 years.

METHOD

Relative and absolute measures of inequality based on the concentration index were used to examine the distribution of indicators of reported health based on domains and summary scores of the SF-36 across occupation-related social classes in both countries.

RESULTS

The degree of inequality is most pronounced in the domains and summary scores of the SF-36 representing aspects of physical health. In regard to comparisons between these countries, there is no significant difference in the distribution of summary scores for physical health. Although there are differences in the summary scores for mental health, there is no evidence of significant inequality in Australia in this aspect of health.

CONCLUSIONS

There is a similar pattern of occupation-related health inequality in the physical health dimensions of the SF-36 health survey for employed males age 18-65 years.

IMPLICATIONS

Given the similarities in the distribution of measures of physical health in the two countries, it would be useful to assess recent English policy initiatives aimed at reducing health inequalities when developing interventions to tackle inequalities in Australia.

Health related quality of life and health status in adult survivors with previously operated complex congenital heart disease

OBJECTIVE

To examine the impact of previously operated complex congenital heart disease on health related quality of life and subjective health status and to determine the relation between these parameters and physical status.

DESIGN

Cross sectional; information on medical follow up was sought retrospectively.

SETTING

Patients were randomly selected from the archives of the paediatric cardiology department, Leiden University Medical Centre, Leiden, The Netherlands, and approached irrespective of current cardiac care or hospital of follow up.

PATIENTS

Seventy eight patients with previously operated complex congenital heart disease (now aged 18-32 years) were compared with the general population.

MAIN OUTCOME MEASURES

Health related quality of life was determined with a specifically developed questionnaire (Netherlands Organisation for Applied Scientific Research Academic Medical Centre (TNO-AZL) adult quality of life (TAAQOL)) and subjective health status was assessed with the 36 item short form health survey (SF-36). Physical status was determined with the objective physical index, Somerville index, and New York Heart Association functional class.

RESULTS

Health related quality of life of the patients was significantly worse than that of the general population in the dimensions gross motor functioning and vitality (p < 0.01). Correlations between health related quality of life and physical status were poor. Patients had significantly worse subjective health status than the general population in the dimensions physical functioning, role functioning physical, vitality, and general health perceptions (p < 0.01). Correlations between subjective health status and physical indices were weak.

CONCLUSION

Adult survivors with previously operated complex congenital heart disease experienced limitations only in the physical dimensions of health related quality of life and subjective health status. Objectively measured medical variables were only weakly related to health related quality of life. These results indicate that, when evaluating health related quality of life, dedicated questionnaires such as the TAAQOL should be used.

Pitfalls of using patient recall to derive preoperative status in outcome studies of total knee arthroplasty

BACKGROUND

It is essential to adjust for the level of preoperative pain and functional status when measuring the outcome of total knee arthroplasty. Some study designs rely on postoperative patient recall to derive preoperative status. In this study, we compared prospectively collected preoperative data with data derived from patient recall of preoperative status three months after total knee arthroplasty.

METHODS

Patients were recruited as part of a prospective observational study of the outcome of primary total knee arthroplasty for osteoarthritis at four centers in the United States, six centers in the United Kingdom, and two centers in Australia. Independent research assistants recruited patients and collected data with use of a uniform documentation system preoperatively and three months postoperatively. Preoperative data included the findings of a clinical history and physical examination, demographic information, socioeconomic status, and scores from two health-status instruments: the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and the Medical Outcomes Study Short Form-36 Health Survey (SF-36). Postoperative data included the WOMAC and SF-36 scores and patient recall of preoperative status on selected items from these health-status measures.

RESULTS

A total of 862 patients were recruited, and recall data were available for 770 patients (89%). The mean age was seventy years (range, thirty-eight to ninety years), and 59% of the patients were women. Comparisons of prospective and recall data on individual pain and function items showed poor-to-fair agreement (weighted kappa, 0.20 to 0.41). Patients recalled significantly more pain than they had reported preoperatively (p < 0.001), but there were random recollection errors for the function items. There was only moderate correlation between the prospective and recalled summary scores for pain (Spearman r = 0.53) and function (Spearman r = 0.48). In addition, 61% of the recalled pain scores and 50% of the recalled function scores differed from the prospective scores by more than 10 points (10% of the total range).

CONCLUSIONS

Patients' recall of preoperative pain and functional status three months after total knee arthroplasty demonstrated only moderate agreement with what the patients had reported prospectively. Researchers who use recall data to derive preoperative status must recognize these limitations when drawing conclusions about the effectiveness of total knee arthroplasty.