Psychometric evaluation of a new proxy-instrument to assess participation in children aged 3-6 years with visual impairment: PAI-CY 3-6

Health-Related Quality of Life Using the KIDSCREEN-27 Questionnaire among Adolescents with High Myopia

Background/Objectives: The aim of the study was to explore Health-Related Quality of Life (HRQoL) using the KIDSCREEN-27 questionnaire among adolescents with high myopia (HM). Methods: Sixty-nine adolescents with HM and 71 healthy participants aged 12-17 years and their parents or legal guardians were enrolled in the study. Results: Adolescents with HM showed significantly lower scores on the Physical Well-Being dimension in comparison with controls (p = 0.003), particularly girls with HM in comparison with girls from the control group (p = 0.008), and 15-17-year-old adolescents in comparison with same-aged controls (p = 0.020). Girls with HM were characterised by significantly worse scores on the Psychological Well-Being dimension compared with boys with HM (p < 0.042). Sociodemographic factors and refractive error, its duration, and acceptance of disease had no impact on HRQoL. Conclusions: HM may have a negative impact on the HRQoL of children, affecting particularly the physical and psychological well-being of girls. It is important that a holistic approach to the treatment of HM in adolescents is taken by measuring their HRQoL as part of the routine diagnostic process. Use of the KIDSCREEN-27 questionnaire seems justified as it allows for determination of the type of intervention required to improve the HRQoL of individuals affected by the disease.

Subjective vision assessment in companion dogs using dogVLQ demonstrates age-associated visual dysfunction

Introduction

Dim light vision as assessed by proxy and clinical tools is commonly impaired in older humans and impacts quality of life. Although proxy visual assessment tools have been developed for dogs, it is unclear if they are sensitive enough to detect subtle visual dysfunction in older dogs. We sought to determine if a newly designed proxy visual function questionnaire could detect age-associated differences in visual behaviors in varying lighting conditions in dogs.

Methods

A 27-item questionnaire (the dog variable lighting questionnaire, dogVLQ) was designed to assess visual behavior in dogs in different lighting settings. We conducted the dogVLQ, a previously validated visual function questionnaire the dog vision impairment score and performed light- and dark-adapted electroretinography (ERG) on a subset of dogs. Questionnaire scores were analyzed for dog age associations using correlation analysis.

Results

Questionnaire responses from 235 dog owners were obtained (122 female, 112 male dogs), 79 of which underwent ERG (43 female, 36 male dogs). Bright light visual behavior was significantly associated with light-adapted bright flash ERG amplitudes, visual behavior in near darkness was associated with dark-adapted ERG amplitudes. The dogVLQ identified worse vision in older dogs in bright light, dim light, and darkness; predicted onset was younger for vision in near darkness. Older dogs had more difficulty navigating transitions between lighting conditions.

Discussion

Subjective dog owner assessment of visual function associates with objective measurement of retinal function in dogs and supports reduced vision-mediated behaviors in older dogs.

Translation and cross-cultural adaptation of a Nepali version of the Dutch Participation and Activity Inventory for Children and Youth (PAI - CY) with visual impairment

Background

Visual impairment is an important cause of disability in children. There is a lack of information on rehabilitation needs and low vision support services for children with visual impairment in Nepal. This is a pilot study designed to translate, culturally adapt and pre-test the Dutch version of the Participation and Activity Inventory for Children and Youth (PAI-CY) with visual impairment aged 7–17 years to develop a Nepali version.

Questionnaires (PAI-CY versions for 7–12 and 13–17 years) were translated using standardized methods and were culturally adapted by a panel of experts. They were pretested to evaluate comprehensibility and relevance among six children with visual impairment and blindness. Finally, participants completed a questionnaire evaluation form.

Results

The translation and cultural adaptation process resulted in the adaptation of nine items to make them suitable for Nepali culture. Most children had comprehensibility problems with some specific items because of vocabulary, sentence structure and the composition of items. Most of the children were satisfied with the questionnaires.

Conclusion

The study resulted in the development of a Nepali version of the PAI-CY. We worked with a small group of content experts and a small but representative sample of children which allowed us to use rigorous translation procedures to address language and cultural differences. A population based study has been planned to investigate the psychometric properties of these questionnaires.

Psychometric properties of the Dutch version Adult Strabismus-20 Questionnaire (AS-20)

PURPOSE

Strabismus often has an impact on a patient's quality of life (QoL). The Adult Strabismus-20 questionnaire (AS-20) is an instrument developed to assess the strabismus-specific QoL. The aim was to investigate several psychometric properties of the Dutch-AS-20 among adult patients with strabismus.

METHODS

Patients with any type of strabismus completed the Dutch-AS-20, the EuroQol five-dimensional questionnaire (EQ-5D-5L) and the Amblyopia and Strabismus Questionnaire (A&SQ) (N = 286). Psychometric properties were evaluated with the use of item response theory (IRT) analysis (graded response model) and by determining the internal consistency, test-retest reliability after two weeks, targeting and measurement precision. Construct validity of the AS-20 was tested against the EQ-5D-5L and the A&SQ.

RESULTS

Principal component analysis indicated a psychosocial and function subscale. After collapsing underutilised response options for 10 items, subsequent fit analysis showed that the function subscale benefitted from removal of two items. Differential item functioning (DIF) was detected on four items for age and gender subgroups, but with minimal impact on the total score. Internal consistency (Cronbach's alpha 0.93 psychosocial and 0.87 function subscale) and test-retest reliability (ICC 0.91 psychosocial and 0.88 function subscale) were sufficient. Targeting and measurement precision of both subscales was appropriate for patients with low to moderate levels of visual and psychosocial functioning but suboptimal for patients with high levels of visual and psychosocial functioning. Correlations were between 0.4 and 0.7 for (subscales of) the Dutch-AS-20 and the A&SQ or EQ-5D-5L, confirming expected construct validity.

CONCLUSIONS

The 18-item Dutch-AS-20 has sound psychometric properties to assess the strabismus-specific QoL among Dutch adult patients with low to moderate levels of visual and psychosocial functioning. Care must be taken when interpreting the results due to lower measurement precision at the higher end of both subscales. In future longitudinal studies, properties to assess treatment effects should be evaluated.

Quality of Life and Participation of Children With Visual Impairment: Comparison With Population Reference Scores

Purpose

The purpose of this study was to investigate quality of life and participation in children aged 3 to 17 years with visual impairment (VI) compared to reference groups and between subgroups with increasing severity levels of VI.

Methods

Parents of children aged 3 to 17 years (n = 500) and children aged 13 to 17 years (n = 75) completed the Child and Adolescent Scale of Participation (CASP). Children aged 7 to 17 years (n = 263) and their parents (n = 255) completed the KIDSCREEN-27 questionnaire to assess quality of life. Scores were compared to age and/or gender-appropriate population-based samples. For the CASP, a comparison was also made with children with chronic conditions or disabilities. The association between severity of VI and quality of life or participation was analyzed with linear regression models.

Results

Children reported significantly worse on Physical Wellbeing and Social Support & Peers, but better on the School Environment KIDSCREEN-27 subscales compared to reference groups. Parents additionally reported worse on Autonomy & Parent Relation. Children's participation was significantly worse compared to a population-based sample, but significantly better compared to children with chronic conditions and disabilities. Having moderate or severe VI/blindness was significantly associated with worse participation, as reported by parents relative to those with no VI.

Conclusions

Quality of life of children with VI is affected especially regarding Physical Wellbeing and Social Support & Peers compared to a reference population, and their participation is considerably worse. Participation was more affected in children with more severe VI. These results contribute to the understanding of the impact of VI. Interventions targeting physical health, social skills, and participation are warranted.

The Michigan Vision-Related Anxiety Questionnaire: A Psychosocial Outcomes Measure for Inherited Retinal Degenerations

OBJECTIVE

We sought to construct and validate a patient-reported outcome measure for screening and monitoring vision-related anxiety in patients with inherited retinal degenerations.

DESIGN

Item-response theory and graded response modeling to quantitatively validate questionnaire items generated from qualitative interviews and patient feedback.

METHODS

Patients at the Kellogg Eye Center (University of Michigan, Ann Arbor, Michigan, USA) with a clinical diagnosis of an inherited retinal degeneration (n = 128) participated in an interviewer-administered questionnaire. The questionnaire consisted of 166 items, 26 of which pertained to concepts of "worry" and "anxiety." The subset of vision-related anxiety questions was analyzed by a graded response model using the Cai Metropolis-Hastings Robbins-Monro algorithm in the R software mirt package. Item reduction was performed based on item fit, item information, and item discriminability. To assess test-retest variability, 25 participants completed the questionnaire a second time 4 to 16 days later.

RESULTS

The final questionnaire consisted of 14 items divided into 2 unidimensional domains: rod function anxiety and cone function anxiety. The questionnaire exhibited convergent validity with the Patient Health Questionnaire for symptoms of depression and anxiety. This vision-related anxiety questionnaire has high marginal reliability (0.81 for rod-function anxiety, 0.83 for cone-function anxiety) and exhibits minimal test-retest variability (ρ = 0.81 [0.64-0.91] for rod-function anxiety and ρ = 0.83 [0.68-0.92] for cone-function anxiety).

CONCLUSIONS

The Michigan Vision-Related Anxiety Questionnaire is a psychometrically validated 14-item patient-reported outcome measure to be used as a psychosocial screening and monitoring tool for patients with inherited retinal degenerations. It can be used in therapeutic clinical trials for measuring the benefit of an investigational therapy on a patient's vision-related anxiety.

The Michigan Retinal Degeneration Questionnaire: A Patient-Reported Outcome Instrument for Inherited Retinal Degenerations

PURPOSE

To create a psychometrically validated patient-reported outcome measure for inherited retinal degenerations.

DESIGN

Qualitative and quantitative patient-reported outcome (PROs) questionnaire development using item response theory validation.

METHODS

One hundred twenty-eight patients with a diagnosis of an inherited retinal degeneration at the Kellogg Eye Center (University of Michigan) were recruited and administered a 166-item questionnaire comprising 7 expert-defined domains. The questionnaire was re-administered 4-16 days later to a subset of 25 participants to assess test-retest variability. Graded response models were fit by Cai's Metropolis-Hastings Robbins-Monro algorithm using the R (version 3.6.3) package mirt. Model data were fit to assess questionnaire dimensionality, to estimate item information, and to score participants. Poorly functioning items were removed, and the model was refit to create the final questionnaire.

RESULTS

The psychometrically validated PROs measure was reduced to a 59-item questionnaire measuring 7 unidimesnional domains: central vision, color vision, contrast sensitivity, scotopic function, photopic peripheral vision, mesopic peripheral vision, and photosensitivity. A total of 39 items were removed because of poor factor loading, low item information, poor person-ability differentiation, or high item-level interdependence. This novel questionnaire produces a reliable domain score for person ability that does not show significant test-retest variability across repeated administration.

CONCLUSIONS

The final PRO questionnaire, known as the Michigan Retinal Degeneration Questionnaire, is psychometrically validated and available for use in the evaluation of patients with inherited retinal degenerations.

First stage psychometric testing of a new instrument for adolescents with visual impairment: the Participation and Activity Inventory for Children and Youth (PAI-CY) 13-17 years

BACKGROUND

To assess participation of children with visual impairment, the Participation and Activity Inventory for Children and Youth (PAI-CY) was recently developed. This study assessed some initial psychometric properties of the PAI-CY 13-17 years version, and investigated its feasibility.

METHODS

Adolescents with visual impairment and their parents (n = 72 dyads) completed the self-report and proxy-report version of the 58-item PAI-CY, an evaluation form and several questionnaires measuring related constructs. Item deletion was informed by item responses, inter-item correlations, test-retest reliability, adolescent-parent agreement and participants' feedback. Known-group validity and concurrent validity with related questionnaires were investigated for the final item-set.

RESULTS

Twelve items had > 20% missing values, whereas 39 items showed floor effects. Eight item pairs showed high inter-item correlations. Test-retest reliability was acceptable for most items (kappa ≥0.4). Evaluation forms showed that over 90% of respondents was neutral to very positive regarding several feasibility aspects such as administration time and comprehensiveness. Adolescent-parent agreement was mostly low. These results informed the deletion of three items. Known-group validity seemed adequate since PAI-CY scores were significantly worse for participants with comorbidity compared to those without. A trend towards worse scores for participants with more severe visual impairment was also observed. Correlations between the PAI-CY and related questionnaires confirmed concurrent validity.

CONCLUSIONS

Initial psychometric properties of the PAI-CY 13-17 were acceptable, although more work is needed to assess other psychometric properties, such as the underlying construct. Following implementation in low vision care to assess participation needs, enabling larger samples, acceptability of the PAI-CY 13-17 to end-users should be carefully monitored, especially if alterations are made based on the current study.

Network Analysis of the Participation and Activity Inventory for Children and Youth (PAI-CY) 7-12 Years with Visual Impairment

Purpose

Children with visual impairment often experience more difficulties regarding participation compared to sighted peers. The Participation and Activity Inventory for Children and Youth (PAI-CY) has recently been developed to assess their participation needs. A novel application in the field of questionnaires is the use of network analysis to explore interrelations between items in order to capture their complex interactions as a reflection of the overall construct of measurement. This study aimed to apply network modeling for the PAI-CY 7–12 from the perspectives of children and their parents.

Methods

Children and their parents (n = 195) completed the 55-item PAI-CY via face-to-face interviews and a web-based survey, respectively. Internal consistency, test-retest reliability, and concordance between children and parents were investigated. Two networks were created, along with visualizations of shared and differential connections between children and parents.

Results

Eight items were deleted. Network structures were dissimilar; for children, connections evolved around social contacts and school items, whereas for parents, mobility, leisure time, acceptance, self-reliance, and communication items prevailed. In the children's network, playing imaginary games, inviting a friend to play at home, and estimating the distance from others were most connected to other items.

Conclusions

This study uniquely identifies connections between items of the PAI-CY 7–12, highlighting the different perspectives parents and children have on what defines participation, possibly implying that they perceive the relevance of various rehabilitation programs differently.

Translational Relevance

Rehabilitation programs aimed at improving the most connected items might positively affect other items in the network, possibly improving children's participation.

Psychometric evaluation of a new proxy-instrument to assess participation in children aged 3-6 years with visual impairment: PAI-CY 3-6

PURPOSE

The Participation and Activity Inventory for Children and Youth 3-6 years (PAI-CY 3-6) was recently developed to assess the participation needs of children with visual impairment (VI) by means of parent-proxy report. This study reports on its psychometric properties.

METHODS

Parents of children aged 3-6 years registered at two low vision rehabilitation centers in the Netherlands were invited to participate and completed the 52-item PAI-CY. Satisfaction with the PAI-CY 3-6 was determined using an evaluation form. Basic item analyses was conducted, after which an item response theory (IRT) model (i.e. the graded response model, GRM) was fitted. Deletion of items was informed by results of item analyses, fulfillment of IRT assumptions, differential item functioning, fit to the GRM and item information content. Face and content validity were considered; professionals from low vision rehabilitation centers were asked for their opinion in the item deletion process. After obtaining a satisfactory set of items, known-group validity, concurrent validity and test-retest reliability were also investigated.

RESULTS

Data of 237 parents were included in the analyses. Various aspects of the PAI-CY 3-6 were perceived as neutral to positive by over 85% of the respondents. After removing 17 items, the remaining 35 items reflected satisfactory fit to the GRM. Known-group validity was supported, since participants with more severe VI and comorbidity scored significantly worse than those with less severe VI and without comorbidity after correcting for potential confounders. Test-retest reliability was adequate, and the PAI-CY showed to have good concurrent validity. Feedback from professionals motivated the maintenance of 3 of the 17 deleted items, although not included in the scoring. Furthermore, two new items were added, resulting in a 40-item instrument.

CONCLUSIONS

The PAI-CY 3-6 has sound psychometric properties and can now be used to assess the participation needs of children aged 3-6 years with VI by means of proxy. Implementation in routine low vision rehabilitation care enables further optimization and investigation of its acceptability and feasibility.