Tests of data quality, scaling assumptions, and reliability of the SF-36 in eleven countries: results from the IQOLA Project. International Quality of Life Assessment

Cross-validation of the Taiwan version of the Moorehead-Ardelt Quality of Life Questionnaire II with WHOQOL and SF-36

Background

Obesity has become a major worldwide public health issue. There is a need for tools to measure patient-reported outcomes. The Moorehead–Ardelt Quality of Life Questionnaire II (MA II) contains six items. The objective of this study was to translate the MA II into Chinese and validate it in patients with morbid obesity.

Methods

The MA II was translated into Chinese and back-translated into English by two language specialists to create the Taiwan version, which was validated by correlations with two other generic questionnaires of health-related quality of life (HRQOL), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and World Health Organization Quality of Life (WHOQOL)-BREF Taiwan version. The convergent validity was accomplished by a series of Spearman rank correlations. Reliability of the MA II Taiwan version was determined by internal consistency obtained by Cronbach’s alpha coefficient and test–retest reliability obtained by intraclass correlation coefficient.

Results

One hundred subjects with morbid obesity were enrolled to test the MA II Taiwan version convergent validity and internal consistency. Test–retest studies (2 weeks apart) were applied to 30 morbidly obese patients. Satisfactory internal consistency was demonstrated by a Cronbach’s alpha coefficient of 0.79. Good test–retest reliability was shown by intraclass correlations ranging from 0.73 to 0.91. The total sum of MA II scores was significantly correlated with all four domains of the WHOQOL-BREF and two major components of SF-36 (all correlations, p < 0.01; range, 0.44–0.64). All six MA II items showed significant correlations with each other (r = 0.34–0.69, p < 0.01), and the total sum of MA II scores was negatively correlated with body mass index (r = −0.31, p < 0.01), indicating a one-dimensional questionnaire of HRQOL.

Conclusions

The MA II Taiwan version is an obesity-specific questionnaire for QOL evaluation with satisfactory reliability and validity. It has the advantages of extensive evaluation for HRQOL, cross-cultural application, rapid completion, high response rates, and an advanced scoring system.

[Relevance of quality of life questionnaires in women with endometriosis]

High recurrence rates have been reported in women treated for endometriosis despite advances in medical and surgical treatments improving both fertility and symptoms. It should therefore be considered a chronic disorder. In this particular setting, the main objectives for practitioners are to limit disease progression, recurrence and to improve quality of life (QOL). Previous studies have demonstrated a relation between an increase in pain intensity and a decrease in QOL. However, visual analogue scales to measure general well-being are insufficient to quantify the impact of endometriosis on QOL. Several generic questionnaires, mainly the SF-36, are available in various languages but are not specific of women with endometriosis. Some specific questionnaires are available but have been validated in English population for the most part rending comparison between countries difficult. Despite these limits, QOL should be systematically monitored over time by a validated questionnaire for this chronic disorder and could be a criterion for therapeutic strategy.

Development of a tool to guide referral of patients with neuromuscular disorders to allied health services. Part two

PURPOSE

The Perceived Limitations and Needs Questionnaire (PLAN-Q) was developed to guide referral for a one-off consultation by occupational therapy (OT), physical therapy (PT), and speech therapy (ST) consultation, to provide a tailor-made advice on allied health interventions. This article reports on the testing of validity and reliability of the PLAN-Q.

METHODS

In the validation study, 208 patients with a broad spectrum of neuromuscular disorders completed the PLAN-Q, Medical Outcome Study short-form 36-item version (SF-36), and the Impact of Participation on Autonomy (IPA) questionnaires. A subsection of 51 patients, whose physical condition was stable, participated in the evaluation of the intra-rater reliability of the questionnaire. The theoretical construct was tested with factorial analysis, subscales were constructed and reliability and validity of the PLAN-Q subscales were assessed.

RESULTS

Factorial analysis resulted in an 18-item self-report questionnaire. Items were grouped into four subscales ('physical capacity', 'transferring', 'oropharyngeal capacity', and 'hand-use'), each with two dimensions ('capacity' and 'need for help'). The internal consistency of all subscales was good (Cronbach's alpha: 0.77-0.94) as well as the intra-rater reliability of the subscales 'physical capacity' and 'transferring' in the 'capacity' dimension (Kappa: 0.70-0.75). The 'need' dimension showed poor intra-rater reliability suggesting that 'need for help' is a variable phenomenon that changes between two points of measurement. The construct validity of the subscales against the SF-36 and the IPA was satisfactory.

CONCLUSION

The PLAN-Q is a valid self-report instrument that measures patients' perception of capacity and needs in domains relevant to referral for a one-off OT, PT, or ST consultation.

Validation of a survey methodology for gastroesophageal reflux disease in China

BACKGROUND

Gastroesophageal reflux disease (GERD) causes a wide range of clinical symptoms and potentially serious complications, but epidemiological data about GERD in China are limited. The aim of this pilot study was to develop and validate a methodology for the epidemiological study of GERD in China.

METHODS

Regionally stratified, randomized samples of Shanghai residents (n = 919) completed Mandarin translations of the Reflux Disease Questionnaire (RDQ), GERD Impact Scale, Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire and 36-item Short Form Health Survey (SF-36). Reliability and construct validity were tested by appropriate statistical analyses.

RESULTS

The response rate was 86%. The test-retest reliability coefficients for the RDQ, GERD Impact Scale, QOLRAD and SF-36 were 0.80, 0.71, 0.93 and 0.96, respectively, and Cronbach's alpha coefficients were 0.86, 0.80, 0.98 and 0.90, respectively. Dimension scores were highly correlated with the total scores for the QOLRAD and SF-36, and factor analysis showed credible construct validity for the RDQ, GERD Impact Scale and SF-36. The RDQ GERD score was significantly negatively correlated with QOLRAD dimensions of food and drink problems and social functioning, and was significantly negatively correlated with all dimensions of the SF-36. All eight of the SF-36 dimensions were significantly correlated with the QOLRAD total score.

CONCLUSION

This study developed and tested a successful survey methodology for the investigation of GERD in China. The questionnaires used demonstrated credible reliability and construct validity, supporting their use in larger epidemiological surveys of GERD in China.

Health status among US Hispanics: ethnic variation, nativity, and language moderation

BACKGROUND

The relationship between health status and Hispanic ethnicities, language, and nativity is poorly understood, due to the limitations and conflicting findings of previous studies.

OBJECTIVES

To examine the effects of language and nativity on health status in Hispanic ethnic subgroups and non-Hispanic whites (whites).

RESEARCH DESIGN

Cross-sectional analyses of data from the 1998-2004 National Health Interview Survey linked to the 1999-2005 Medical Expenditure Panel Survey. Health status was regressed on race/ethnicity, interview language, and nativity, with adjustment for demographic and socioeconomic variables.

SUBJECTS

A total of 16,489 Hispanics (13,522 Mexicans, 778 Cubans, 1360 Puerto Ricans, and 829 Dominicans) and 45,422 whites.

MEASURES

SF-12 mental (MCS-12) and physical (PCS-12) component summary scores.

RESULTS

In adjusted analyses, Mexicans had significantly higher MCS-12 scores than other Hispanics and whites, with the largest advantage noted for Spanish-speaking Mexicans. Ethnic origin * nativity interaction effects were significant for both MCS-12 [adjusted Wald test, F (3236) = 7.27, P = 0.0001] and PCS-12 [F (3236) = 4.75, P = 0.0031]. Continental US-born Mexicans had worse mental and physical health status than non-US-born Mexicans. By contrast, continental US birth was associated with better mental health status for Cubans and Dominicans, and better physical health status for Puerto Ricans.

CONCLUSIONS

Complex interactions exist among language, nativity, ethnicity, and health status among Hispanics. Mexicans have better health status than whites and other Hispanics, and the moderating effects of nativity and language differ for Mexicans compared with other Hispanics. Future research should approach Hispanics as a diverse grouping rather than a monolithic entity.

Measures in chiropractic research: choosing patient-based outcome assessments

OBJECTIVE

Outcome assessment normally used in research can support the therapeutic process by tracking patient symptoms and function and offering a common language to clinicians and researchers. This study's objectives were to (1) identify patient-based outcomes assessments used in published chiropractic studies, (2) describe a framework for identifying appropriate sets of measures, and (3) address the challenges associated with these measures relevant to chiropractic.

METHODS

This literature review identified and evaluated the most commonly used to outcome measures in chiropractic research. Instruments were evaluated in terms of feasibility, practicality, economy, reliability, validity, and responsiveness to clinical change. A search of PubMed and Index to Chiropractic Literature (from inception to June 2006) was performed.

RESULTS

A total of 1166 citations were identified. Of these, 629 were selected as relevant. The most common patient-based outcomes assessments instruments identified were the Oswestry Pain/Disability Index, Visual Analog Scale, and Short Form 36.

CONCLUSIONS

The integration of outcome measures is consistent with current national initiatives to enhance health care quality through performance measurement and can also be used to further the field of chiropractic health care research. Outcome measures are both a research tool and a means by which providers can consistently measure health care quality. Based upon this review, there is a wide range of outcome measures available for use in chiropractic care. Those most commonly cited in the literature are the numeric rating scale, Visual Analog Scale, Oswestry Pain/Disability Index, Roland-Morris Low Back Pain and Disability Questionnaire, and Short Form 36.

Health services research

The discipline of health services research, often loosely referred to as outcomes research, is primarily focused on the study of access to care, costs of care, and quality of care. Access to care includes everything that facilitates or impedes the actual use of medical services. Costs of care include financial and nonfinancial payments by insurers and individuals for medical services as well as the opportunity cost of lost wages and the societal cost of decreased productivity. Quality of care encompasses elements of the structure, process, and outcome of medical care.

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.

Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions

OBJECTIVES

To present nationally representative findings on prevalence, sociodemographic correlates, disability, and comorbidity of narcissistic personality disorder (NPD) among men and women.

METHOD

Face-to-face interviews with 34,653 adults participating in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions conducted between 2004 and 2005 in the United States.

RESULTS

Prevalence of lifetime NPD was 6.2%, with rates greater for men (7.7%) than for women (4.8%). NPD was significantly more prevalent among black men and women and Hispanic women, younger adults, and separated/divorced/widowed and never married adults. NPD was associated with mental disability among men but not women. High co-occurrence rates of substance use, mood, and anxiety disorders and other personality disorders were observed. With additional comorbidity controlled for, associations with bipolar I disorder, post-traumatic stress disorder, and schizotypal and borderline personality disorders remained significant, but weakened, among men and women. Similar associations were observed between NPD and specific phobia, generalized anxiety disorder, and bipolar II disorder among women and between NPD and alcohol abuse, alcohol dependence, drug dependence, and histrionic and obsessive-compulsive personality disorders among men. Dysthymic disorder was significantly and negatively associated with NPD.

CONCLUSIONS

NPD is a prevalent personality disorder in the general U.S. population and is associated with considerable disability among men, whose rates exceed those of women. NPD may not be as stable as previously recognized or described in the DSM-IV. The results highlight the need for further research from numerous perspectives to identify the unique and common genetic and environmental factors underlying the disorder-specific associations with NPD observed in this study.

Are there meaningful longitudinal changes in health related quality of life--SF36, in cardiac rehabilitation patients?

BACKGROUND

This study aimed to observe changes in quality of life and minimal clinical important differences of quality of life over time in cardiac rehabilitation patients and to compare these with published normal data.

METHODS

In this non-randomised study, SF36 questionnaires were completed by 187 patients recruited to a Phase III cardiac rehabilitation multidisciplinary outpatient programme. Data was collected at beginning, end and six months after Phase III cardiac rehabilitation programme.

RESULTS

There were significant improvements in physical functioning, role limitation due to physical function, pain and general health perception scales, over the above time frame, from both a statistically and a mean clinical important difference point of view. These improvements occurred mainly during the cardiac rehabilitation programme phase.

CONCLUSIONS

These improvements meant that patients six months post-cardiac rehabilitation were only 5% below the quality of life for an aged matched normal group. However patients still had significant deficits in physical role and emotional role limitations. Suitable measurement of quality of life on an individual basis, supported by normal values is needed. This would facilitate the identification of shortfalls in patient quality of life and the subsequent tailoring of care to address these individualised patient needs.

Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVES

To present nationally representative findings on prevalence, sociodemographic correlates, disability, and comorbidity of borderline personality disorder (BPD) among men and women.

METHOD

Face-to-face interviews were conducted with 34,653 adults participating in the 2004-2005 Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Personality disorder diagnoses were made using the Wave 2 Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version.

RESULTS

Prevalence of lifetime BPD was 5.9% (99% CI = 5.4 to 6.4). There were no differences in the rates of BPD among men (5.6%, 99% CI = 5.0 to 6.2) and women (6.2%, 99% CI = 5.6 to 6.9). BPD was more prevalent among Native American men, younger and separated/divorced/widowed adults, and those with lower incomes and education and was less prevalent among Hispanic men and women and Asian women. BPD was associated with substantial mental and physical disability, especially among women. High co-occurrence rates of mood and anxiety disorders with BPD were similar. With additional comorbidity controlled for, associations with bipolar disorder and schizotypal and narcissistic personality disorders remained strong and significant (odds ratios > or = 4.3). Associations of BPD with other specific disorders were no longer significant or were considerably weakened.

CONCLUSIONS

BPD is much more prevalent in the general population than previously recognized, is equally prevalent among men and women, and is associated with considerable mental and physical disability, especially among women. Unique and common factors may differentially contribute to disorder-specific comorbidity with BPD, and some of these associations appear to be sex-specific. There is a need for future epidemiologic, clinical, and genetically informed studies to identify unique and common factors that underlie disorder-specific comorbidity with BPD. Important sex differences observed in rates of BPD and associations with BPD can inform more focused, hypothesis-driven investigations of these factors.

Which aspects of non-clinical quality of care are most important? Results from WHO's general population surveys of "health systems responsiveness" in 41 countries

Quality of care research has reached some agreement on concepts like structure, process and outcome, and non-clinical versus clinical processes of care. These concepts are commonly explored through surveys measuring patient experiences, yet few surveys have focused on patient, or "user", priorities across different quality dimensions. Population surveys on priorities can contribute to, although not replace participation in, policy decision making. Using 105,806 survey interview records from the World Health Organization's (WHO's) general population surveys in 41 countries, this paper describes the relative importance of eight domains in the non-clinical quality of care concept WHO calls "health systems responsiveness". Responsiveness domains are divided into interpersonal domains (dignity, autonomy, communication and confidentiality) and structural domains (quality of basic amenities, choice, access to social support networks and prompt attention). This paper explores variations in domain importance by country-level variables (country of residence, human development, health system expenditure, and "geographic zones") and by subpopulations defined by sex, age, education, health status, and utilization. Most respondents selected prompt attention as the most important domain. Dignity was selected second, followed by communication. Access to social support networks was identified as the least important domain. In general, convergence in rankings was stronger across subpopulations within countries than across countries. Yet even across diverse countries, there was more convergence than divergence in views. These results provide a ranking of quality of care criteria for consideration during health reform processes further to the usual emphasis on clinical quality and supply-side efficiency.

Metabolic syndrome and health-related quality of life in obese individuals seeking weight reduction

BACKGROUND

No previous research has examined the association between metabolic syndrome (MetSyn) and health-related quality of life (HRQoL) using standard criteria for defining MetSyn. We hypothesized that MetSyn would be associated with lower HRQoL on measures of physical and mental health.

METHODS AND PROCEDURES

Participants were 361 individuals in two randomized weight loss trials. MetSyn was defined by the National Cholesterol Education Panel criteria. The Medical Outcomes Study, Short Form-36 (SF-36) was used to assess HRQoL. Differences in HRQoL and in clinical and psychosocial characteristics were compared among participants with and without MetSyn. Multiple regression was used to determine predictors of HRQoL.

RESULTS

MetSyn was associated with lower scores on the physical function and general health subscales of the SF-36 and on the physical component summary (PCS) score. This association remained after controlling for age or depression but was eliminated by controlling for BMI. MetSyn was not associated with lower mental quality of life, a higher depression score, tobacco or alcohol use, or a higher rate of psychosocial stressors.

DISCUSSION

Individuals with MetSyn reported lower HRQoL. This appeared to be an effect of increased weight, rather than a unique effect of MetSyn. Larger studies are needed to assess whether MetSyn may have an independent effect on HRQoL.

Cross-cultural comparison of the Scoliosis Research Society Outcomes Instrument between American and Japanese idiopathic scoliosis patients: are there differences?

STUDY DESIGN

A comparative study.

OBJECTIVE

To report a preliminary evaluation of the Scoliosis Research Society Outcomes Instrument (SRS-24) and determine whether differences in baseline scores exist between American and Japanese patients with idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Because the SRS outcomes instrument was primarily introduced for the American population, baseline scores in the Japanese population might differ from the American population. A comparative study using the SRS instrument between American and Japanese patients with idiopathic scoliosis has not been reported.

METHODS

Two comparable groups of 100 idiopathic scoliosis patients before spinal fusion were separated into American (A) and Japanese (J). There were no statistically significant differences between the groups for gender (A: 9 men/91 women vs. J: 13 men/87 women), age (A: 15.0 +/- 2.4 vs. J: 14.9 +/- 3.8), main curve location (A: 77 thoracic/23 lumbar, J: 76 thoracic/24 lumbar), main curve Cobb angle (A: 50.5 +/- 5.2 vs. J: 51.1 +/- 8.7), and thoracic kyphosis (A: 20.9 +/- 14.3 vs. J: 19.9 +/- 12.1) (P > 0.05, for all comparisons). Patients were evaluated using the first section of the SRS-24 which was divided into 4 domains: total pain, general self-image, general function, and activity. SRS-24 scores were statistical compared in individual domains and questions using the Mann-Whitney U test.

RESULTS

American patients had significantly lower scores in pain (P < 0.0001, A: 3.7 +/- 0.8 vs. J: 4.3 +/- 0.4), function (P < 0.01, A: 3.9 +/- 0.6 vs. J: 4.2 +/- 0.5), and activity (P < 0.0001, A: 4.5 +/- 0.8 vs. J: 4.9 +/- 0.3) domains compared with Japanese patients. Japanese patients had significantly lower scores in the self-image (P < 0.0001, A: 4.0 +/- 0.7 vs. J: 3.5 +/- 0.5) domain. With regard to individual questions, there were significant differences in the scores between the 2 groups for all questions except 5 and 13 (P < 0.05, for all comparisons).

CONCLUSION

SRS-24 scores in the Japanese idiopathic scoliosis population differed from that of the American population. Japanese patients had less back pain, a negative self-image regarding back deformity, higher general physical function, and daily activity. It is highly probable that patient's perceptions differ due to cultural differences, which affect SRS-24 scores so a cross-cultural comparison of the SRS instrument content is necessary in the future.

Investigating differential item functioning by chronic diseases in the SF-36 health survey: a latent trait analysis using MIMIC models

OBJECTIVES

Differential item functioning (DIF) is present when respondents of unique subgroups endorse certain items differently given the respondents have the same underlying ability. This study investigates the presence of DIF regarding chronic illnesses among items of the physical functioning (PF) and mental health (MH) domains of the SF-36 health survey.

METHODS

Multiple indicators multiple causes (MIMIC) model was applied to data extracted from the Kaiser Permanente database for members who completed the SF-36 during 1994-1995 (N = 7538). DIF effects were evaluated for sociodemographic variables and for indicators of 5 chronic conditions: hypertension, rheumatic conditions, diabetes, respiratory diseases, and depression. An iterative strategy with backward selection was applied to build DIF models, which were estimated by weighted least squares. The Hochberg procedure was applied to P values for multiple tests.

RESULTS

After controlling for the selected covariates and the latent ability, DIF was present in 3 items for hypertension, one for respiratory diseases, and one for diabetes. Adjusting for DIF did not modify the overall pattern of exogenous variables' effects on PF or MH, except Hispanic and other ethnicity on PF, education on MH became insignificant; and black ethnicity on PF, old ages and other ethnicity on MH became significant.

CONCLUSIONS

Considering the number of items and disease subgroups compared, the presence of DIF was minimal among items of the PF and MH domains of the SF-36. DIF had little effect on comparisons of sociodemographic or disease groups.

Measuring quality of health care from the user's perspective in 41 countries: psychometric properties of WHO's questions on health systems responsiveness

OBJECTIVE

To evaluate, for different populations, psychometric properties of questions on "health systems responsiveness", a concept developed by World Health Organization (WHO) to describe non-clinical and non-financial aspects of quality of health care. DATA SOURCES/STUDY SETTING/DATA COLLECTION: The 2000-2002 WHO Multi-Country Study comprised 70 general population surveys. Forty-one surveys were interviewer-administered, from which we extracted respondent records indicating ambulatory and inpatient health services use (excluding long-term institutions) in the previous 12 months (50,876 ambulatory and 7,964 hospital interviews).

STUDY DESIGN

We evaluated feasibility, reliability, and construct validity using 33 items with polytomous response options, comparing responses from populations identified by countries, sex, age, education, health and income.

PRINCIPAL FINDINGS

Average item missing rates ranged from 0 to 16%. Domain-specific alpha coefficients exceeded 0.7 in 7 (of 9) cases. Average intertemporal reliability was acceptable in 6 (of 10) sites, where Kappas ranged from 0.54 to 0.79, but low in 4 sites (K < 0.5). Kappa statistics were higher for male, educated and healthier populations than for female, less educated and less healthy populations. Factor solutions confirmed the domain structure of 7 domains (only 7 were operationalized for ambulatory settings). As in other studies, higher incomes and age was associated with more positive responsiveness reports and ratings.

CONCLUSIONS

Quality issues addressed by WHO's questions are understood and reported adequately across diverse populations. More research is needed to interpret user-assessed quality of care comparisons across population groups within and between countries.

Cross-Cultural Adaptation and Validation of Singapore Malay and Tamil Versions of the EQ-5D

Introduction: The aims of this study were to cross-culturally adapt and evaluate the validity of the Singaporean Malay and Tamil versions of the EQ-5D. Materials and Methods: The EQ5D was cross-culturally adapted and translated using an iterative process following standard guidelines. Consenting adult Malay- and Tamil-speaking subjects at a primary care facility in Singapore were interviewed using a questionnaire (including the EQ-5D, a single item assessing global health, the SF-8 and sociodemographic questions) in their respective language versions. Known-groups and convergent construct validity of the EQ-5D was investigated by testing 30 a priori hypotheses per language at attribute and overall levels. Results: Complete data were obtained for 94 Malay and 78 Indian patients (median age, 54 years and 51 years, respectively). At the attribute level, all 16 hypotheses were fulfilled with several reaching statistical significance (Malay: 4; Tamil: 5). At the overall level, 42 of 44 hypotheses related to the EQ-5D/ EQ-VAS were fulfilled (Malay: 22; Tamil: 20), with 21 reaching statistical significance (Malay: 9; Tamil: 12). Conclusion: In this study among primary care patients, the Singapore Malay and Tamil EQ-5D demonstrated satisfactory known-groups and convergent validity. Key words: Primary Health Care, Psychometrics, Quality of Life

Outcome evaluation of surgical and nonsurgical management of lumbar disc protrusion causing radiculopathy

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To assess health-related quality of life (HRQOL) following either lumbar discectomy or nonoperative care for lumbar disc protrusion causing radiculopathy (LDPR).

SUMMARY OF BACKGROUND DATA

Although LDPR is a prevalent disorder, little progress has been made in defining the optimal treatment strategy.

METHODS

A total of 497 patients (333 in the lumbar discectomy group and 164 in the nonoperative group) were analyzed. Patients completed baseline as well as 6- and 12-month generic (SF-36) and disease-specific (NASS Lumbar Spine Instrument) HRQOL measures. Demographic comparisons between groups, using standard descriptive statistics, were made. Multivariate analysis was used to obtain a regression coefficient for the primary outcome: the neurogenic symptoms score (NSS) from the NASS instrument. Outcome measures were compared between groups and to published normative data.

RESULTS

The mean baseline score was lower in the surgical group (30.9 nonoperative, 25.3 surgical), indicative of greater baseline disability. The scores at follow-up were approximately equivalent (44.6 nonoperative, 43.8 surgical). However, neither group returned to an age-matched normative NSS (51.6) within the timeframe of the study. Using regression analysis, the outcome "change in NSS" was not associated with variable "treatment group."

CONCLUSIONS

HRQOL after LDPR, as measured in this study by NASS NSS, demonstrated similar improvement in both groups and was not meaningfully associated with the treatment received, within the timeframe of this study. At follow-up, all outcome measures remained lower than population normative scores, suggesting that, irrespective of treatment, an element of disability remained.

Impact of psychological distress on pain and function following knee arthroplasty

BACKGROUND

Preoperative psychological distress has been reported to be an important risk factor for poor outcome following lower-extremity arthroplasty. We determined the independent impact of preoperative psychological distress on three, twelve, and twenty-four-month WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) pain and function scores and on change scores over those time periods.

METHODS

Data were obtained from an international group of 952 patients in thirteen centers participating in the Kinemax Outcomes Study. Patients completed the WOMAC and Short Form-36 (SF-36) questionnaires. The mental health (MH) scale of the SF-36 was used to quantify the impact of psychological distress on WOMAC pain and function scores. We also dichotomized patients into groups with and without psychological distress on the basis of evidence-based cut-points. Repeated-measures models were used to derive mean preoperative and three, twelve, and twenty-four-month WOMAC pain and function scores and general linear models were used to derive change scores for patients with and without psychological distress after adjustment for covariates.

RESULTS

Psychological distress, when examined on a continuous scale, was found to predict pain and function at all time-points. WOMAC pain scores for psychologically distressed patients were 3 to 5 points lower, depending on the time-frame, than the scores for the non-distressed patients, after adjustment for covariates. WOMAC function scores did not differ significantly between the two groups following surgery. The changes in the WOMAC pain and function scores for the psychologically distressed patients were not significantly different from those for the non-distressed patients.

CONCLUSIONS

Many patients with psychological distress demonstrate a substantial decrease in that distress following surgery. Patients who are distressed have slightly worse pain preoperatively and for up to two years following knee arthroplasty as compared with patients with no psychological distress. With the exception of preoperative scores, these differences are not likely to be measurable at the individual patient level. WOMAC pain and function change scores do not differ between patients with and without distress after adjustment for covariates.

LEVEL OF EVIDENCE

Prognostic Level I.

Reliability and Validity of the Incontinence Quality of Life Questionnaire in Patients With Neurogenic Urinary Incontinence

OBJECTIVE

To assess the reliability, validity, responsiveness, and minimally important difference (MID) of the Incontinence Quality of Life (I-QOL) questionnaire in patients with urinary incontinence due to neurogenic detrusor overactivity.

DESIGN

Randomized, double-blind, multicenter, placebo-controlled study.

SETTING

Eight centers across Belgium, France, and Switzerland.

PARTICIPANTS

Patients with urinary incontinence due to neurogenic detrusor overactivity inadequately managed on oral anticholinergics. Fifty-nine patients (spinal cord injury, n=53; multiple sclerosis, n=6) were enrolled.

INTERVENTION

Single dose of botulinum toxin type A (Botox) (200 or 300 U) or placebo.

MAIN OUTCOME MEASURES

I-QOL questionnaire completed at screening and over a 24-week post-treatment period.

RESULTS

The Cronbach alpha ranged from .79 to .93, indicating that I-QOL is a reliable measure of QOL in neurogenic urinary incontinence patients. No item had more than 5.1% missing or out of range values. With the exception of 2 items, questions showed acceptable item-scale correlation and scaling success results varied by domain. Post-treatment correlations indicated acceptable construct validity. The I-QOL was responsive to improvements in symptoms. MID values ranged from 4 to 11 points.

CONCLUSIONS

Results suggest that I-QOL is a reliable, valid, and responsive measure of incontinence-related QOL in neurogenic patients.

The associations between living conditions, demography, and the ‘impact of cancer’ scale in tumor-free cancer survivors: a NOCWO study

GOALS OF WORK

The "impact of cancer" scale (IOC) is a new questionnaire that explores attitudes in the physical, psychological, social, and spiritual/existential domains in cancer survivors. This study explores the associations between demography, living conditions (LCs), and the IOC dimensions in disease-free Norwegian survivors who have been treated for breast, prostate, or testicular cancer.

MATERIALS AND METHODS

A questionnaire covering demography, LCs, and the IOC was mailed to 852 cancer survivors; 459 (54%) participated. A living condition index (LCI) was calculated based on self-reported education, employment, annual income, health, housing expenditures, and social participation.

MAIN RESULTS

Survivors with a low LCI level viewed their situation significantly worse on four of five negative IOC dimensions than those with high LCI level. No significant LCI-related differences were observed for the mean scores of positive IOC dimensions. Significant associations were observed between gender, health status, employment, and five to six IOC dimensions. LCs were more often associated with the negative IOC dimensions than the positive ones.

CONCLUSIONS

The significant associations between LCs and dimensions of the IOC in tumor-free cancer survivors show that LCs should be considered when health care professionals assist cancer survivors in dealing with the impact the cancer experience had on their lives.

MOS-SF 36

The objective was to study the construct validity of the MOS SF-36 (Medical Outcome Study, short form questionnaire, version of 36 items) using structural equation modeling (SEM). Despite the widespread use of the questionnaire, several problems with the measurement model have been shown in the past, and it is highly disputable whether the computation of two component (summary) scales according to the published algorithm is a valid condensation. The SEM was conducted with the data of N = 2,874; the SF-36 was part of a questionnaire given prior to acupuncture treatment. The results indicated poor construct validity of the proposed structure of the first and second order factor solutions. First and foremost, contrary to the algorithm stated in the manual, the two component scales are not uncorrelated. Second, the overall fit of the original measurement model does not reflect the data structure very well. The current measurement model is discussed and starting points for revisions are provided.

Panic episodes among patients with diabetes

OBJECTIVE

The objective of this study was to examine the prevalence of panic episodes in persons with diabetes and the demographic, behavioral and clinical characteristics associated with panic symptoms in persons with diabetes.

METHOD

A survey mailed to 4385 patients with diabetes assessed recent experiences of panic episodes, depression, diabetes symptoms, quality of life, disability, smoking status and body mass index. Automated medical record data were used to measure diabetes treatment, hemoglobin A1c (Hb(A1c)) levels, diabetes complications and medical comorbidity.

RESULTS

One hundred ninety-three (4.4%) participants reported recent panic episodes, among whom 54.5% also met criteria for major depression. After accounting for the effects of depression, panic episodes were associated with higher Hb(A1c) values, increased diabetic complications and symptoms, greater disability and lower self-rated health and functioning.

CONCLUSION

Panic is strongly associated with decrements in disease status and functioning. Since panic is often comorbid with depression, efforts to address psychological disorders among persons with diabetes may need to pay increased attention to anxiety and mood disorders.

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.

Translation and validation of the SF-36 Health Survey for use among Turkish and Moroccan ethnic minority cancer patients in The Netherlands

In this study, the SF-36 Health Survey was translated into two oral Moroccan languages and the existing Turkish version was culturally adapted for use in The Netherlands, and was tested among 79 Moroccan and 90 Turkish cancer patients. There were normal levels of missing item responses but a higher administration time. With minor exceptions, the scale structure of the SF-36 was confirmed and the reliability of the scales met the 0.70 criterion for group comparisons. The questionnaire distinguished clearly between subgroups formed on the basis of performance status and was responsive to change in performance status over time. Some evidence of differential item function (DIF) was found in both ethnic groups. These results support the use of the SF-36 among Turkish and Moroccan cancer patients in The Netherlands. Additional studies are needed to confirm the psychometrics of the questionnaire when used among these ethnic minority groups in other Western European countries.

Alcohol consumption and out-patient services utilization by abstainers and drinkers

AIMS

Previous studies have found that abstainers utilize out-patient health services more than alcohol consumers. The aim of this study was to investigate this relationship further by including several confounding variables and effect modifiers. It was hypothesized that abstainers utilize more health services because they have less social resources, practice more risky health behaviours, have poorer self-reported health and suffer more from chronic diseases.

DESIGN AND PARTICIPANTS

Cross-sectional health survey of a random sample of adults aged 20-64 in Pomerania, Germany. The response rate was 68.8%. Alcohol consumption was assessed using a quantity-frequency measure and categorized into past-year abstainers, low-risk, medium-risk and high-risk drinkers. Confounders and effect modifiers included socio-demographic and health-related variables.

FINDINGS

Abstainers had a 43% higher rate (rate ratio = 1.43, 95% CI = 1.24, 1.63) of physician visits compared to low-risk drinkers, adjusting for age and gender. Medium-risk and high-risk drinkers did not differ from low-risk drinkers in terms of out-patient visits. Further regression adjustment for socio-economic covariates, self-reported health status and chronic diseases suggested that abstainers used more out-patient services because they were more ill than drinkers. The effect of mental health status and the number of chronic diseases on out-patient visits was greater for abstainers than drinkers.

CONCLUSIONS

The relation between alcohol consumption and out-patient services is explained partly by poorer health among the abstainers. Further research is needed to affirm these results, such as transferring this evidence to the utilization of in-patient health services.

A Pilot Study to Modify the SF-36V Physical Functioning Scale for Use With Veterans With Spinal Cord Injury

OBJECTIVE

To develop a valid and reliable spinal cord injury (SCI) specific physical functioning (PF) scale for the Veterans Health Administration (VHA) version of the 36-Item Short-Form Health Survey.

DESIGN

A mixed qualitative and quantitative research design was used. In phase 1, a pool of SCI-specific PF items was generated based on focus groups with patients and health care providers. In phase 2, the psychometric properties of the SCI-specific PF scale were established.

SETTING

A VHA SCI center.

PARTICIPANTS

The sample consisted of valid responses from 359 veterans with traumatic SCI who were seen at a VHA SCI center during the prior year (2002).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Physical functioning in people with SCI.

RESULTS

Exploratory factor analysis was conducted separately on respondents with lower neurologic-level injuries (paraplegia, 53% [n=190]) and those with higher neurologic-level injuries (tetraplegia, 45% [n=163]) and identified 9 items loading on 1 factor in both groups. These 9 items were included in separate item response theory (IRT) model analyses for each subgroup. Based on the IRT analysis, 1 item was eliminated, resulting in an 8-item, SCI-specific PF scale.

CONCLUSIONS

Although several of the items in the SCI-specific PF scale showed floor effects, particularly in people with tetraplegia, we found excellent reliability and strong support of convergent and divergent validity of the scale.

A new condition specific quality of life measure for the blind and the partially sighted in Sub-Saharan Africa, the IOTAQOL: methodological aspects of the development procedure

In Mali, blind and partially sighted people represent 1.2% of the population. Good quality and low cost ophthalmologic care is available, but, unfortunately, is insufficiently taken advantage of. In order to contribute to the analysis of this situation a valid and reliable questionnaire was needed to take the patient's perspective into account. Because of face validity concerns, it was not possible to merely translate an existing questionnaire. Thus we decided to develop a new questionnaire directly in one of the main languages of Mali: Bambara. This involved the setting of a study team composed of social and health science specialists, the majority of whom were native Bambara speakers. The overall project consisted in the iteration of three main steps (1) Conceptual clarification and operationalization of this concept. (2) Qualitative steps: qualitative interviews, focus groups and content analysis. (3) Quantitative steps: statistical analysis of an initial try-out survey (143 participants) and a validation survey (420 participants). This approach yields satisfying results. Indeed, the final version of the IOTAQOL has good psychometric properties. Thus, this interviewer administered instrument can be used to measure health-related quality-of-life in Mali and the methodology that we used could serve as a basis for similar projects.

Measuring quality of life in women with endometriosis: tests of data quality, score reliability, response rate and scaling assumptions of the Endometriosis Health Profile Questionnaire

BACKGROUND

To test the data quality, scaling assumptions and scoring algorithms underlying the Endometriosis Health Profile-30 (EHP-30) questionnaire: a questionnaire developed to measure the health-related quality of life (HRQoL) of women with endometriosis.

METHODS

A cross-sectional postal survey to 727 women with surgically confirmed endometriosis recruited from an existing genetic linkage study (OXEGENE), The National Endometriosis Society (NES), UK and the outpatient gynaecology clinics of the Women's Centre, John Radcliffe Hospital, Oxford. Tests of data quality included secondary factor analysis, internal reliability consistency, descriptive statistics of the data, missing data levels, floor and ceiling effects and corrected item to total correlation scores.

RESULTS

Six hundred and ten women (83.9%) returned the questionnaire. Secondary factor analysis verified the domain structure of the EHP-30. All 11 dimensions were internally reliable with Cronbach's alpha scores ranging from 0.80 to 0.96. Missing response rates ranged from 0.2 to 1.3%, and all items were found to be most highly correlated with their own (corrected) scale.

CONCLUSIONS

Results confirmed the factor structure, scoring and scaling assumptions of the questionnaire. The high rate of data completeness indicated that the EHP-30 was acceptable and understandable to the respondents, thereby verifying its suitability for measuring the HRQoL of women with endometriosis.

Malnutrition affects quality of life in gastroenterology patients

AIM: To investigate the association between malnutrition and quality of life in patients with benign gastrointestinal disease.

METHODS: Two hundred patients (104 wellnourished and 96 malnourished) were assessed according to the Subjective Global Assessment, anthropometric measurements and bioelectrical impedance analysis. Quality of life was determined with the validated Medical Outcomes Study 36-item Short-Form General Health Survey (SF 36). Muscle function was assessed by hand grip strength and peak flow.

RESULTS: Body mass index, body cell mass, arm muscle area and hand grip strength were significantly lower in the malnourished patients. Quality of life was generally lower when compared to norm values. Seven out of eight quality of life scales (excluding bodily pain) were significantly reduced in the malnourished patients. Comparing patients with liver cirrhosis and inflammatory bowel disease (IBD), patients with IBD experienced significantly lower values in the perception of bodily pain,social functioning and mental health. Malnourished liver cirrhotics suffered reductions in more scales (six out of eight) than malnourished IBD patients did (four out of eight).

CONCLUSION: Quality of life is generally low in benign gastrointestinal disease and is further reduced in patients who are classified as malnourished. It appears that liver cirrhosis patients experience a higher quality of life than IBD patients do, but the impact of malnutrition seems to be greater in liver cirrhosis than in IBD.

Malnutrition affects quality of life in gastroenterology patients

AIM: To investigate the association between malnutrition and quality of life in patients with benign gastrointestinal disease.

METHODS: Two hundred patients (104 wellnourished and 96 malnourished) were assessed according to the Subjective Global Assessment, anthropometric measurements and bioelectrical impedance analysis. Quality of life was determined with the validated Medical Outcomes Study 36-item Short-Form General Health Survey (SF 36). Muscle function was assessed by hand grip strength and peak flow.

RESULTS: Body mass index, body cell mass, arm muscle area and hand grip strength were significantly lower in the malnourished patients. Quality of life was generally lower when compared to norm values. Seven out of eight quality of life scales (excluding bodily pain) were significantly reduced in the malnourished patients. Comparing patients with liver cirrhosis and inflammatory bowel disease (IBD), patients with IBD experienced significantly lower values in the perception of bodily pain,social functioning and mental health. Malnourished liver cirrhotics suffered reductions in more scales (six out of eight) than malnourished IBD patients did (four out of eight).

CONCLUSION: Quality of life is generally low in benign gastrointestinal disease and is further reduced in patients who are classified as malnourished. It appears that liver cirrhosis patients experience a higher quality of life than IBD patients do, but the impact of malnutrition seems to be greater in liver cirrhosis than in IBD.

Assessment of differential item functioning for demographic comparisons in the MOS SF-36 health survey

OBJECTIVE

To investigate whether items of the Medical Outcomes Study (MOS) 36-Item Short-Form Health Status Survey (SF-36) exhibited differential item functioning (DIF) with respect to age, education, race, and gender.

METHODS

The data for this study come from two large national datasets, the MOS and the 1990 National Survey of Functional Health Status (NSFHS). We used logistic regression to identify items exhibiting DIF.

RESULTS

We found DIF to be most problematic for age comparisons. Items flagged for age DIF were vigorous activities, bend/kneel/stoop, bathing or dressing, limited in kind of work, health in general, get sick easier than others, expect health to get worse, felt calm and peaceful, and all four vitality items. Items flagged for education DIF include vigorous activities, health in general, health is excellent, felt calm and peaceful, and been a happy person. Vigorous activities, walk more than a mile, health in general, and expect health to get worse were identified as DIF when comparing African-Americans with whites. No items were identified for gender DIF.

CONCLUSIONS

We found several consistent patterns of DIF using two national datasets with different population characteristics. In the current study, the effect of DIF rarely transferred to the scale level. Further research is needed to corroborate these results and determine qualitatively why DIF may occur for these specific items.

Using preference-based measures to assess quality of life in stuttering

PURPOSE

The purpose of this study was to determine whether standard pharmaco-economic preference methods can be used to assess perceived quality of life in stuttering.

METHOD

Seventy-five nonstuttering adults completed a standardized face-to-face interview that included a rating scale, standard gamble, and time trade-off preference measures for 4 health states (your health and mild, moderate, and severe stuttering) in the context of 2 anchor states (perfect health and death).

RESULTS

Results showed mean utility values between .443 for severe stuttering estimated using the rating scale technique and .982 for respondents' own current health estimated using a standard gamble technique. A two-way repeated measures analysis of variance and post hoc tests showed significant effects for method, health state, and the interaction.

CONCLUSIONS

These results confirm that utility estimates can differentiate between stuttering severity levels and that utility scores for stuttering conform to the known properties of data obtained using these standard measurement techniques. These techniques, therefore, can and should be further investigated as potential contributors to complete measurement protocols for the study and treatment of stuttering.

Quality of Life and its Relation to Cancer-Related Stress in Women of Families with Hereditary Cancer without Demonstrated Mutation

BACKGROUND

Although quality of life (QoL) and mental distress in women belonging to familial cancer families have been studied, little is known on these matters in women with absence of demonstrated mutations. The aim of this study was to examine QoL and cancer-related distress in such women.

METHODS

About 330 women at risk for familial cancers in the absence of demonstrated mutations were invited to the study. About 239 women (72%) (risk group) completed the Short Form 12 (SF-12) and the Impact of Event Scale (IES). The SF-12-findings were compared to the age-adjusted findings from the general female population (controls).

RESULTS

The risk group had significantly better physical QoL than controls, while no significant difference was found for mental QoL. Within the risk group the type of familial cancer did not make a significant difference in QoL, but to have a father with cancer or a deceased parent, was associated with increased risk of being a case with low QoL. Mental QoL showed moderate correlation with cancer-related distress.

CONCLUSIONS

Women belonging to familial cancer families in the absence of demonstrated mutations had at least as good QoL as controls in spite of living with a permanent cancer-related threat.

Health-related quality of life and impact of antiviral treatment in Chinese patients with chronic hepatitis C in Taiwan

AIM

To evaluate health-related quality of life (HRQOL) in Chinese patients with chronic hepatitis C (CH-C), and the impact of antiviral treatment.

METHODS

Short Form 36 (SF-36) Health-related Quality of Life Questionnaires to interview CH-C patients, and age- and sex-matched control subjects at outpatient clinics of a medical center in Taiwan were used. Data were transformed to scores for comparisons of eight major SF-36 domains. We also enrolled consecutive CH-C patients who completed one course of antiviral treatment (interferon alpha with ribavirin), and measured the HRQOL before, at the 12th wk of treatment, at the end of treatment, and at mo 6, after stopping the treatment to evaluate the impact of antiviral treatment.

RESULTS

A total of 371 outpatients were enrolled, including 182 with CH-C and 189 age- and sex-matched subjects without CH-C. CH-C subjects had obviously lower educational status (P<0.01). Mean scores of domains in general health, physical functioning, role-physical, role-emotional, vitality, and mental health of the SF-36 were significantly lower in subjects with CH-C than those without CH-C (P<0.05). In an analysis of 47 CH-C patients who received and completed the whole course of antiviral treatment, mean scores of all domains were significantly lower at wk 12 of treatment compared to baseline. The scores returned to pretreatment values by the end of treatment, but were significantly increased at mo 6 after stopping the treatment. Among the 47 CH-C patients, 21 had sustained responses and 26 had non-sustained responses to antiviral treatment. Compared to pretreatment values, subjects with sustained responses had significantly lower social functioning scores at wk 12 of treatment, and scores for all SF-36 domains returned to pretreatment values, and increased significantly at mo 6 after stopping the treatment. For non-sustained virological responders, scores of all SF-36 domains significantly decreased at wk 12 of treatment, and did not increase significantly by the end of treatment, or at mo 6 after stopping the treatment when compared to the pretreatment values.

CONCLUSION

HRQOL in CH-C patients is significantly impaired in most SF-36 domains. Antiviral treatment impaired HRQOL of CH-C subjects during early treatment, mainly in non-sustained virological responders, and improved at mo 6 after stopping the treatment, mainly in sustained virological responders.

Validity of the Spanish version of the Chronic Liver Disease Questionnaire (CLDQ) as a standard outcome for quality of life assessment

The Chronic Liver Disease Questionnaire (CLDQ) measures the impact on quality of life of chronic liver diseases, regardless of underlying etiology. The aim of this study was to develop a Spanish version of the CLDQ, and to assess its acceptability, reliability, validity, and sensitivity to change. The forward and back-translation method by bilingual translators, with expert panel and pilot testing on patients, was used for the adaptation. The final version was self-administered, together with the Short Form-36 Health Survey (SF-36), on 149 consecutive patients with chronic liver disease. Child-Turcotte-Pugh scores were evaluated by a physician. To assess reproducibility and responsiveness the CLDQ was readministered to a subsample of stable patients and to those who had received a liver transplant. Validity was evaluated via exploratory factor analysis, the CLDQ pattern across severity groups, and correlation coefficients with "itching" and SF-36 scores. Cronbach's alpha and Intraclass Correlation Coefficient for CLDQ global score were 0.93 and 0.90, respectively, demonstrating good reliability. Validity was supported by correlations of the CLDQ with SF-36 and "itching," and CLDQ severity gradient (global score means were 5.5, 5.2, 5.0, and 4.5 in patients with no cirrhosis, cirrhosis Child-Turcotte-Pugh A, B, and C, respectively; P = 0.012). Responsiveness was shown by a high CLDQ improvement in patients who had received liver transplant (mean change = -1.4; P < 0.001). In conclusion, the Spanish CLDQ is reliable, valid, responsive, and equivalent to the original. These findings support its use as a standard outcome for patients with chronic liver diseases within the whole severity range, from "no cirrhosis" to transplant recipients, both in Spanish and international studies.

Psychometric Properties of the DUKE Health Profile-adolescent Version (DHP-A): A Generic Instrument for Adolescents

PURPOSE

Quality of life in general population of adolescents has been scarcely documented. The study was aimed at evaluating the psychometric properties of the DUKE Health Profile-Adolescent version (DHP-A), an adaptation from the adult version.

MATERIAL AND METHOD

Feasibility and construct validity were assessed in a sample of 618 adolescents from school settings. Test-retest reliability was assessed in another sample of 100 adolescents at 2 weeks interval. Construct validity was assessed in groups by gender, age and existence of a health problem.

RESULTS

The DHP-A, a short instrument of HRQOL, easy to administer, proved its ability to discriminate between boys and girls, with or without a health problem, for all of health and dysfunction dimensions (p < 0.05). Its reliability is also acceptable for three health dimensions and anxiety, depression (ICC = 0.68-0.72), moderate for social, perceived health, self-esteem and pain (ICC = 0.43-0.59), and debatable for disability (ICC = 0.22) (single item).

CONCLUSION

The initial testing of the adolescent version (DHP-A) indicates that the psychometric properties are acceptable and will provide a useful tool for the assessment of health status in adolescents. Three single-item dimensions (perceived health, pain and disability) should be interpreted with caution.

Psychometric properties of a Russian version of the SF-12 Health Survey in a refugee population

This project examined psychometric properties of a Russian translation of the 12-item Short-Form health survey questionnaire (SF-12) to assess physical and mental health status in members of the Russian-speaking refugee population. Translation and adaptation included (a) cross-cultural adaptation; (b) translation; (c) pre-testing; and (d) analysis of validity, reliability, and internal consistency. Seventeen Russian-speaking patients at a Russian psychiatric clinic were recruited for the study and were compared to a sample of 42 Russian-speaking members of the community. The instrument showed internal consistency when evaluated with coefficient alpha. As compared with community subjects, clinic patients had significantly lower scores, reflecting poorer physical and mental well being.

Prevalence and factors of sexual problems in Chinese males and females having sex with the same-sex partner in Hong Kong: a population-based study

A cross-sectional, anonymous telephone survey was conducted to examine sexual problem (SP) among sexually active, Chinese homosexual adults in Hong Kong. Of the homosexual respondents, 49.1% of males and 75.6% of females reported at least one SP, of whom 36.0 and 65.7% of the males and females, respectively, felt very bothered by the SP. The prevalence of SP ranged from 3.6% (pain) to 21.8% (premature orgasm) for men and from 16.9% (anxiety) to 39.3% (lubrication problems) for females. Female homosexuals were less likely to be satisfied with their sex life and more bothered by an SP than heterosexual females and homosexual males. There were few significant differences between homosexual and heterosexual males. Female homosexuals were also more likely than male homosexuals to experience lack of orgasm and pain during intercourse. Being bothered by SP was associated with erectile dysfunction among homosexual men and lubrication problems and lack of pleasure among the homosexual women.

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.

Use of the scoliosis research society outcomes instrument to evaluate patient outcome in untreated idiopathic scoliosis patients in Japan: part I: comparison with nonscoliosis group: preliminary/limited review in a Japanese population

STUDY DESIGN

This preliminary study evaluates untreated Japanese patients with idiopathic scoliosis using the Scoliosis Research Society Outcomes Instrument (SRS-24).

OBJECTIVES

To determine the baseline patient outcome score using the SRS-24 for untreated Japanese scoliosis patients compared with a nonscoliosis group.

SUMMARY OF BACKGROUND DATA

The SRS instrument with 24 questions was developed to help evaluate patient-perceived outcomes of idiopathic scoliosis treatment. Evaluation of untreated Japanese idiopathic scoliosis patients using the SRS instrument has not been reported.

METHODS

Japanese idiopathic scoliosis patients (n = 141) (mean age, 13.6 years; range, 10-17 years) with a Cobb angle of more than 20 degrees who were not treated with a brace or surgery, were evaluated in comparison with a nonscoliosis group (healthy junior high school students; n = 72) using the SRS-24. The scoliosis group was categorized as mild deformity group with a major curve Cobb angle of less than 30 degrees, moderate deformity group with 30 degrees to 49 degrees, and severe deformity group with more than 50 degrees. The patients were evaluated using section 1 (15 questions) of the SRS-24, which was divided into four domains: total pain, general self-image, general function, and activity. Reliability, as determined by internal consistency, was validated using Cronbach's alpha for these domain scales.

RESULTS

The severe deformity group had the lowest scores compared with the other deformity groups and the nonscoliosis group in pain (P < 0.0001) and self-image (P < 0.05) domains. The scores for questions 3 (P < 0.0001) and 5 (P < 0.0001), evaluation of self-image of back appearance, were significantly lower in the scoliosis group than those in the nonscoliosis group. This tendency was more significant in the patients with greater curve magnitude. Scores for questions 14 and 15, evaluation of general self-image, in the scoliosis group were, however, higher than those in the nonscoliosis group. Internal consistency using Cronbach's alpha was 0.57 (pain), 0.27 (general self-image), -0.08 (general function), and 0.15 (overall level of activity).

CONCLUSION

Untreated scoliosis patients with severe deformity were inclined to complain of being self-conscious or distressed regarding their back appearance compared with age- and sex-matched control adolescents. The control group was inclined to have, however, a negative general self-image compared with the patients group. Internal consistency using Cronbach's alpha for all domains was considerably low. The baseline of the SRS-24 scores in the Japanese population might differ from that of the Western population because of differences in national culture. Therefore, further study is necessary to clarify the validity of the SRS-24 domains for Japanese patients.