Resolving Dimensionality Problems With WHOQOL-BREF Item Responses

Adequacy of the WHOQoL-BREF to Assess the Quality of Life of Victims of Armed Conflicts

There is a deterioration in the quality of life (QoL) of survivor victims of warlike conflicts. Because there is a need to guarantee the effectiveness of assessment tools for these populations, we studied the adequacy of the World Health Organization Quality of Life Questionnaire (WHOQoL-BREF) to assess the QoL of 1,136 surviving victims of the armed conflict in Colombia. Although this questionnaire has yielded promising results, questions remain about its psychometric suitability for specific populations. We used model modification at the item level, comparisons of models with different factor structures, and dimensionality analysis to address the psychometric problems encountered. Dimensionality analysis using a bifactor model suggests that WHOQoL-BREF total scores might be a more appropriate way of reporting results when model fit adequacy is not reached. Conclusions are offered on the psychometric properties of the WHOQoL-BREF, the evaluation of special populations, and possible strategies to address future questionnaire modifications.

Quality of life in south-eastern Australia: normative values for the WHOQOL-BREF in a population-based sample of adults

OBJECTIVES

The abbreviated World Health Organisation Quality of Life tool (WHOQOL-BREF) is a short-form quality of life (QoL) assessment commonly used worldwide in both healthy and ill populations. Normative data for the Australian general population are limited. The objective of this study was to present normative data for the WHOQOL-BREF based on a general population sample. A secondary aim was to explore sociodemographic factors related to QoL.

DESIGN

Population-based cross-sectional study.

PARTICIPANTS

929 men and 830 women aged 24-94 years participating in the Geelong Osteoporosis Study.

OUTCOME MEASURES

The 26-item WHOQOL-BREF.

RESULTS

Means and SD for each domain are presented by age group and sex. Percentile scores were also generated. Mean scores for WHOQOL-BREF domains were 74.52 (SD=16.22) for physical health, 72.07 (SD=15.35) for psychological, 72.87 (SD=18.78) for social relationships and 79.68 (SD=12.55) for environment. We identified significant associations between sociodemographic factors and WHOQOL-BREF domains. Notably, being married or in a relationship was associated with increased odds for high QoL across all four WHOQOL-BREF domains: physical health (women OR 2.46, 95% CI 1.36 to 4.44, p=0.003), psychological (men OR 2.07, 95% CI: 1.20 to 3.55, p=0.009; women OR 2.15, 95% CI 1.21 to 3.81, p=0.009), social relationships (men OR 2.28, 95% CI 1.29 to 4.04, p=0.005; women OR 2.77, 95% CI 1.42 to 5.41, p=0.003) and environment (women OR 2.07, 95% CI 1.13 to 3.80, p=0.019).

CONCLUSIONS

This study provides population norms for the WHOQOL-BREF based on a representative sample of Australian adults. Our results will be useful to researchers and clinicians who can use these data as a reference point for interpreting WHOQOL-BREF scores.

Bifactor exploratory structural equation modeling: A meta-analytic review of model fit

Multivariate behavioral research often focuses on latent constructs—such as motivation, self-concept, or wellbeing—that cannot be directly observed. Typically, these latent constructs are measured with items in standardized instruments. To test the factorial structure and multidimensionality of latent constructs in educational and psychological research, Morin et al. (2016a) proposed bifactor exploratory structural equation modeling (B-ESEM). This meta-analytic review (158 studies, k = 308, N = 778,624) aimed to estimate the extent to which B-ESEM model fit differs from other model representations, including confirmatory factor analysis (CFA), exploratory structural equation modeling (ESEM), hierarchical CFA, hierarchical ESEM, and bifactor-CFA. The study domains included learning and instruction, motivation and emotion, self and identity, depression and wellbeing, and interpersonal relations. The meta-analyzed fit indices were the χ²/df ratio, the comparative fit index (CFI), the Tucker-Lewis index (TLI), the root mean square error of approximation (RMSEA), and the standardized root mean squared residual (SRMR). The findings of this meta-analytic review indicate that the B-ESEM model fit is superior to the fit of reference models. Furthermore, the results suggest that model fit is sensitive to sample size, item number, and the number of specific and general factors in a model.

Melhores Práticas para sua Análise Fatorial Exploratória: Tutorial no Factor

RESUMO Contexto: a análise fatorial exploratória (AFE) é um dos métodos estatísticos mais utilizados em administração. No entanto, sua prática corrente coexiste com regras de bolso e heurísticas proferidas há meio século. Objetivo: o propósito deste artigo é apresentar as melhores práticas e recomendações recentes para uma AFE típica em administração através de uma solução prática acessível aos pesquisadores. Métodos: nesse sentido, além de serem discutidas as práticas correntes versus as práticas recomendadas, ilustra-se um tutorial com dados reais no Factor, um software ainda pouco conhecido na área de administração, porém freeware, fácil de usar (point and click) e poderoso. O passo a passo ilustrado no artigo, além das discussões levantadas e de um exemplo adicional, também é disponibilizado no formato de vídeos tutoriais. Conclusão: através da metodologia didática proposta (artigo-tutorial + vídeo-tutorial), incentivamos os pesquisadores/metodologistas que dominam alguma técnica particular a fazerem o mesmo. Especificamente sobre a AFE, esperamos que a apresentação do software Factor, como uma primeira solução, possa transcender as regras de bolso e heurísticas correntes ultrapassadas, ao tornar acessíveis as melhores práticas para os pesquisadores da administração.

Best Practices for Your Exploratory Factor Analysis: A Factor Tutorial

ABSTRACT Context: exploratory factor analysis (EFA) is one of the statistical methods most widely used in administration; however, its current practice coexists with rules of thumb and heuristics given half a century ago. Objective: the purpose of this article is to present the best practices and recent recommendations for a typical EFA in administration through a practical solution accessible to researchers. Methods: in this sense, in addition to discussing current practices versus recommended practices, a tutorial with real data on Factor is illustrated. The Factor software is still little known in the administration area, but is freeware, easy-to-use (point and click), and powerful. The step-by-step tutorial illustrated in the article, in addition to the discussions raised and an additional example, is also available in the format of tutorial videos. Conclusion: through the proposed didactic methodology (article-tutorial + video-tutorial), we encourage researchers/methodologists who have mastered a particular technique to do the same. Specifically about EFA, we hope that the presentation of the Factor software, as a first solution, can transcend the current outdated rules of thumb and heuristics, by making best practices accessible to administration researchers.

The Impact of Clinical, Biochemical, and Echocardiographic Parameters on the Quality of Life in Patients with Heart Failure with Reduced Ejection Fraction

Despite significant advances in HF diagnosis and treatment over the recent decades, patients still characterize poor long-term prognosis with many recurrent hospitalizations and reduced health-related quality of life (HRQoL). We aimed to check the potential relationship between clinical, biochemical, or echocardiographic parameters and HRQoL in patients with HF with reduced ejection fraction (HFrEF). We included 152 adult patients hospitalized due to chronic HFrEF. We used the WHOQoL-BREF questionnaire to assess HRQoL and GNRI to evaluate nutritional status. We also analyzed several biochemical parameters and left ventricle ejection fraction. Forty (26.3%) patients were hospitalized due to HF exacerbation and 112 (73.7%) due to planned HF evaluation. The median age was 57 (48–62) years. Patients with low somatic HRQoL score had lower transferrin saturation (23.7 ± 11.1 vs. 29.7 ± 12.5%; p = 0.01), LDL (2.40 (1.80–2.92) vs. 2.99 (2.38–3.60) mmol/L; p = 0.001), triglycerides (1.18 (0.91–1.57) vs. 1.48 (1.27–2.13) mmol/L; p = 0.006) and LVEF (20 (15–25) vs. 25 (20–30)%; p = 0.003). TIBC (64.9 (58.5–68.2) vs. 57.7 (52.7–68.6); p = 0.02) was significantly higher in this group. We observed no associations between HRQoL and age or gender. The somatic domain of WHOQoL-BREF in patients with HFrEF correlated with the clinical status as well as biochemical and echocardiographic parameters. Assessment of HRQoL in HFrEF seems important in everyday practice and can identify patients requiring a special intervention

Factor structure, measurement invariance and psychometric properties of the Quality of Life Scale WHOQOL-BREF in the Ecuadorian context

BACKGROUND

The short version of the World Health Organization Quality of Life questionnaire (WHOQOL-BREF) is a popular instrument used to assess quality of life. The objective of this study was to evaluate the following psychometric properties: structural validity, convergent validity, internal consistency, and measurement invariance across sex of the WHOQOL-BREF in a sample of Ecuadorian adults.

METHODS

We used a sample of undergraduates (n = 987) to assess the WHOQOL-BREF original four-factor structure, a model with correlated factors, a hierarchical model, and two models resulting from the exploratory factor analysis and exploratory graph analysis. All the models were evaluated using confirmatory factor analysis.

RESULTS

The results of the exploratory factor analysis and exploratory graph analysis suggest that the items are organized into four factors, although differently from the original version and the orthogonality assumption is not maintained. The confirmatory factor analysis shows that the original WHOQOL-BREF structure with correlated factors presents adequate psychometric properties. However, we propose a four-factor structure that has the best psychometric properties and adequate internal consistency. The results of the measurement invariance show that strict and strong invariance is achieved between men and women. Convergent validity analysis reveals moderate correlations with self-esteem, resilience, and social support.

CONCLUSIONS

Despite the original version of the WHOQOL-BREF with correlated factors has acceptable psychometric properties in the Ecuadorian context, we propose a version with a different organization of its items, which is consistent with the findings of other investigations.

Assessing general and autism-relevant quality of life in autistic adults: A psychometric investigation using item response theory

Although many interventions and services for autistic people have the ultimate goal of improving quality of life (QoL), there is relatively little research on how best to assess this construct in the autistic population, and existing scales designed for non-autistic individuals may not assess all meaningful facets of QoL in the autistic population. To address this need, the autism spectrum QoL form (ASQoL) was recently developed as a measure of the autism-relevant quality of life. However, the psychometrics of the ASQoL have not been examined beyond the authors' initial validation study, and important properties such as measurement invariance/differential item functioning (DIF) have not yet been tested. Using data from 700 autistic adults recruited from the Simons Foundation's SPARK cohort, the current study sought to perform a comprehensive independent psychometric evaluation of the ASQoL using item response theory, comparing its performance to a newly-proposed brief measure of general QoL (the WHOQOL-4). Our models revealed substantial DIF by sex and gender in the ASQoL, which caused ASQoL scores to grossly underestimate the self-reported QoL of autistic women. Based on a comparison of latent variable means, we demonstrated that observed sex/gender differences in manifest ASQoL scores were the result of statistical artifacts, a claim that was further supported by the lack of significant group differences on the sex/gender-invariant WHOQOL-4. Our findings indicate that the ASQoL composite score is psychometrically problematic in its current form, and substantial revisions may be necessary before valid and meaningful inferences can be made regarding autism-relevant aspects of QoL. LAY SUMMARY: Quality of life (QoL) is an extremely important outcome for autistic people, but many of the tools that are used to measure it does not take into account how QoL may be different for autistic people. Using data from 700 autistic adults, we examined the measurement properties of the autism spectrum quality of life form (ASQoL), a new measure of QoL designed specifically for autistic people. Our results indicate that the ASQoL shows a pronounced sex/gender bias, which causes it to underestimate QoL in autistic women. This bias needs to be eliminated before the ASQoL can be successfully used to measure QoL in the autistic population.

Phantom sensation and quality of life among patients with lower-limb amputations in the region of Juiz de Fora, Minas Gerais: a cross-sectional study

An amputation is an irreversible event that causes social, psychological, and functional consequences that reduces the quality of life of the amputee. Phantom pain generally is reported by 50 to 80% of amputees.

Objective

To describe the pain and phantom sensation and quality of life among lower-limb amputees.

Methods

This was a cross-sectional study carried out in the region of Juiz de Fora, state of Minas Gerais, Brazil. Inclusion criteria were being a patient in one of two hospitals in the region at the time of the interview and having at least one lower-limb amputation. A total of 20 amputees were included in the analysis. The interview questionnaire had items adapted from the Groningen Questionnaire Problems After Leg Amputation - describing the frequency and discomfort of phantom pain and sensation, causes and the level of the amputation, as well as the WHOQOL-BREF, for assessing quality of life.

Results

Most participants were women (55%) and had a mean age of 55.6 years (SD=14.8). Femoral amputation was the most prevalent (65%), and diabetes (40%) was the main reason for amputation. 29% of amputees classified the phantom pain as moderate or severe, and 15% claimed daily frequency of this phenomenon. As for phantom pain, only 6% stated daily frequency. The mean quality of life was 4.1 (SD=1.1, five score means very satisfied), the physical domain of quality of life had the lowest mean (3.4, SD=0.7).

Conclusions

Phantom sensation and pain were prevalent among lower-limb amputees who were, in general, less satisfied with their physical domain of quality of life.

Validation of the WHOQOL-Bref: psychometric properties and normative data for the Norwegian general population

Background

The World Health Organization’s Quality of Life Questionnaire (WHOQOL-Bref) is a frequently used instrument to assess the quality of life in both healthy and ill populations. Inquiries of the psychometric properties of the WHOQOL-Bref report that the validity and reliability is generally satisfactory. However, some studies fail to support a four-factor dimensionality; others report poor reliability of the social and environmental domain; and there may be some challenges of supporting construct validity across age. This paper evaluates the psychometric properties of the Norwegian WHOQOL-Bref and extends previous research by testing for measurement invariance across age, gender and education level. In addition, we provide updated normative data for the Norwegian population.

Methods

We selected a random sample of the Norwegian population (n = 654) aged 18–75 years. Participants filled out the WHOQOL-Bref, the Utrecht Work Engagement Scale and various sociodemographic variables.

Results

We found an acceptable convergent and discriminate validity and internal consistency of the physical, psychological and environmental domains, but a marginal reliability was found for the social domain. The factor loadings were invariant across gender, education and age. Some items had low factor loadings and explained variance, and the model fit for the age group 60–75 years were less satisfactory.

Conclusions

The original four-factor dimensionality of the WHOQOL-Bref displayed a better fit to the data compared to the one-factor solution and is recommended for use in the Norwegian population. The WHOQOL-Bref is suitable to use across gender, education and age, but for assessment in the oldest age group, the WHOQOL-Old module could be a good supplementary, but further studies are needed.

Mental and Physical Factors Influencing Wellbeing among South Korean Emergency Workers

Emergency workers are frequently exposed to hazardous situations and such life patterns can influence their wellbeing. This study examined the relationships among South Korean emergency workers’ precedents and consequences of positive emotion, engagement, relationship, meaning, and achievement (PERMA), a wellbeing concept, and offered solutions. A total of 597 emergency workers in Daegu, South Korea, participated in a survey. This study measured post-traumatic stress disorder syndrome, burnout, depression, PERMA, quality of life, life satisfaction, and sleep quality to test the relationships. Results demonstrated that post-traumatic stress disorder syndrome and burnout predicted distracting sleep behavior and sleep health. Depression was significantly related to PERMA. The better the emergency workers’ PERMA was, the better their quality of life and life satisfaction were. PERMA significantly predicted sleep behavior, a portion of sleep quality. Depression had an indirect influence on quality of life mediated by PERMA. Post-traumatic stress disorder syndrome, burnout, and PERMA were significant predictors of low sleep health and sleep behavior. The results indicate that South Korean emergency workers struggle with depression and sleep quality. As the data were collected during the coronavirus disease 19 pandemic, individual efforts and relevant programs to improve South Korean emergency workers’ PERMA and sleep quality in a crisis are recommended. Possible solutions to improve the wellbeing of South Korean emergency workers are suggested.

Composite outcome measurement in clinical research: the triumph of illusion over reality?

Composite measures that combine different types of indicators are widely used in medical research; to evaluate health systems, as outcomes in clinical trials and patient-reported outcome measurement. The potential advantages of such indices are clear. They are used to summarise complex data and to overcome the problem of evaluating new interventions when the most important outcome is rare or likely to occur far in the future. However, many scientists question the value of composite measures, primarily due to inadequate development methodology, lack of transparency or the likelihood of producing misleading results. It is argued that the real problems with composite measurement are related to their failure to take account of measurement theory and the absence of coherent theoretical models that justify the addition of the individual indicators that are combined into the composite index. All outcome measures must be unidimensional if they are to provide meaningful data. They should also have dimensional homogeneity. Ideally, a specification equation should be developed that can predict accurately how organisations or individuals will score on an index, based on their scores on the individual indicators that make up the measure. The article concludes that composite measures should not be used as they fail to apply measurement theory and, consequently, produce invalid and misleading scores.

Long-Term Morphologic Changes on Sagittal Synostosis Patients Who Underwent a Modified Pi Technique

BACKGROUND

There are paucity of studies focused on the long-term assessment of the craniofacial changes after a pi-plasty procedure and self-reported quality of life outcomes. Thus, this study aimed to assess long-term morphologic changes and quality of life of patients with sagittal synostosis who underwent surgery with a modified pi-plasty.

METHODS

Consecutive patients with sagittal synostosis who underwent surgery and had more than 5 years of follow-up and standard preoperative and 1, 3, and 5 years right profile view photographs were included. Nasofrontal angle and angle of total facial convexity were evaluated using computerized photogrammetric measurements. Additionally, quality of life outcome was evaluated by the Quality of Life Scale Short Form.

RESULTS

The total facial convexity angle and nasofrontal angle increased significantly (P < 0.05), with a P-value of 0.013 and 0.012, respectively. Patients had quality of life scores >80 in all of the 4 domains, with the highest scores being: physical health domain 80.0 ± 0, psychologic domain 85.0 ± 5, social relationships domain 86.6 ± 0, and environmental domain 98.13 ± 2.42.

CONCLUSION

Facial angles significantly changed over 5 years of follow-up. Self-reported quality of life instrument showed that patients are satisfied with their own appearance, contributing positively to their quality of life.

Measuring quality of life in ALS/MND: validation of the WHOQOL-BREF

Objectives: The World Health Organization Quality of Life-BREF Scale (WHOQOL-BREF) is a generic QOL measure with four domains covering Physical, Psychological, Social and Environment. Providing the opportunity to contrast QoL with other conditions, or with population norms, the current study had three aims: 1) can the established domains of the WHOQOL-BREF be validated within a large ALS/MND population; 2) can a total score be validated and 3) can they provide interval level measurement? Methods: Data were obtained from the Trajectories of Outcomes in Neurological Conditions study. Internal construct validity was determined by fit of the data to the Rasch measurement model. Results: 636 participants with ALS/MND were included. All domains, except the Social domain, showed satisfactory fit to the Rasch model. All were unidimensional, and showed no Differential Item Functioning by age, gender, or onset type. Finally, a total score was validated from a bi-factor perspective. Conclusions: The WHOQOL-BREF is valid for use in populations with ALS/MND and can be analyzed to yield interval level measurement: It offers a range of domains that reflect QOL, which can be used for parametric analysis and for comparison with other conditions or general populations, two advantages for its inclusion as a trial outcome measure and for observational studies.

Can whole body vibration exercises promote improvement on quality of life and on chronic pain level of metabolic syndrome patients? A pseudorandomized crossover study

Quality of life (QoL) is one of the most important health outcome concepts expressed subjectively. Chronic pain (CP) is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Taking into account the poor QoL and the CP already described in metabolic syndrome (MSy) individuals, this study aimed to evaluate the effects of whole body vibration exercises (WBVE) on these parameters in this population. Thirty-three MSy patients were divided in subgroups A [whole body vibration exercise group (WBVeG), n = 17, 15 females/2 males, 61.1 ± 8.4 yr] and B (control group, n = 16, 14 females/2 males, 58.2 ± 9.1 yr). Subgroup A performed 10 sessions (2 times/wk) of WBVE (18 min/session, with a frequency from 5 up to 14 Hz and a peak-to-peak displacement of 2.5, 5.0, and 7.5 mm) on a side-alternating vibrating platform (VP). Subgroup B did the same protocol, but the VP was turned off. The individuals answered the World Health Organization Quality of Life bref (WHOQoL-bref) questionnaire before the first and after the 10th session. The chronic pain level (CPL) was measured by a numeric rating scale (0-10) before and at the end of each session. Significant improvements were found in physical health (P = 0.05) and psychological health (P = 0.04) domains of WHOQoL-bref in WBVeG. A significant acute reduction of the CPL was found in the WBVeG after the protocol, considering the first session and at the last session. WBVE marginally improved physical health and psychological health and decrease the CPL in acute interventions.NEW & NOTEWORTHY Metabolic syndrome patients experience poor quality of life, frequently associated with lack of exercise and bad dietary habits. Additionally, factors such as obesity, neuromusculoskeletal impairment, and peripheral endothelial dysfunction result in a chronic pain level. Whole body vibration exercise might represent a suitable physical therapy, since it is easy to perform, low cost, safe, and capable of promoting an improvement of quality of life and reducing chronic pain level during acute interventions in metabolic syndrome individuals.

Construct Validity of the EUROHIS-QOL for Rehabilitation Assessment

The use of the EUROHIS as a brief measure of quality of life (QOL) in applied settings is increasingly commonplace, including in rehabilitation assessment contexts. However, there are concerns about the validity of data produced by the measure, chief amongst which is the latent structure underlying scores. This article reports on research conducted to investigate the dimensionality of scores derived from the EUROHIS. In addition, the factorial invariance of the retained model across gender as well as latent mean differences in QOL over age, employment status, and psychiatric severity were examined. Based on 251 responses to the EUROHIS by compensable accident victims, support was found for a complex one-factor model, which was found to be partially replicable across gender. Some evidence for differential item functioning across gender, age, and employment status was found. Finally, a U-shaped effect of age on QOL, characterized by a mid-life nadir, as well as effects of psychiatric severity on QOL, and a marginally significant effect of employment status were evident. Collectively, though the results of the present study yield validation data for the EUROHIS, they also raise concerns about the measure. We offer some tentative guidelines for working with the measure for both researchers and practitioners.