A qualitative exploration of the content and face validity of preference-based measures within the context of dementia

How do children understand and respond to the EQ-5D-Y-3L? A mixed methods study in a community-based sample of 6-12-year-olds

BACKGROUND

The EQ-5D-Y-3L is widely used for measuring and valuing HRQoL in paediatric populations. This mixed methods study used the EQ-5D-Y-3L measure and applied a retrospective think-aloud approach to examine the self-report validity in children of varying chronological age.

METHODS

A mixed methods study was conducted in a community-based sample of 39 children aged 6-12 years. In a semi-structured interview, children self-completed the EQ-5D-Y-3L and then engaged in retrospective think-aloud. Conversations were audio-recorded and transcribed for analysis in NVivo using the Tourangeau four-stage response model framework to assess comprehension, judgment, recall, and response mapping issues. Fisher's exact test was used to assess the differences between child-self reported HRQoL across subgroups. The inter-rater agreement between child-parent dyads was assessed with CCC for overall HRQoL and Gwet's AC1 for dimension level HRQoL.

RESULTS

Overall, response issues were detected in n = 18 (46%) children. Comprehension issues were apparent in the "having pain or discomfort" dimension where children found it challenging to understand 'discomfort'. Recall-related issues were observed where children's responses were influenced by their typical tendencies (e.g., being usually worried) or past incidences (e.g., feeling pain sometimes). Judgement-related issues were the most common, particularly in the "doing usual activities" dimension, where children tended to respond based on their self-perceived ability to engage in activities rather than health-related limitations. None of the participants were found to have problems with response mapping. A healthy lifestyle that included diet and exercise was a notable consideration in EQ VAS ratings. The younger age groups had a higher proportion of response issues (6-7 years: 64%, 8-10 years: 62%), compared to older children (11-12 years: 20%). Moreover, children with response issues demonstrated significantly lower EQ-5D-Y-3L scores (mean = 0.78, se = 0.04) as compared to those without (mean = 0.95, se = 0.02) (p-value < 0.001). The overall inter-rater agreement was higher for those without any response issues (CCC = 0.33) than those with (CCC = 0.14). Additionally, higher agreement was noted across all the five dimensions in the subgroup with no response issues relative to those with.

CONCLUSIONS

Children in the general community may have different perceptions of HRQoL when responding to the EQ-5D-Y-3L possibly due to their limited experience with health-related challenges. The retrospective think-aloud approach adopted highlighted the relatively higher prevalence of response issues in the younger children (ages < 11 years), indicating the need for careful interpretation of self-reported HRQoL using the current version of the EQ-5D-Y-3L in this population.

Appropriateness of the EQ-HWB for Use in Residential Aged Care: A Proxy Perspective

BACKGROUND AND OBJECTIVE

The EQ Health and Wellbeing (EQ-HWB) is a new generic quality-of-life measure for use in evaluating interventions in health, public health and social care. This study aimed to explore proxies' views regarding the appropriateness of the EQ-HWB for measuring residents' quality of life living in residential aged care facilities.

METHODS

Qualitative think-aloud and semi-structured interviews were conducted with family members and aged care staff across three facilities in Melbourne, Australia. Proxies completed the 25-item EQ-HWB proxy version 2 (i.e. proxy-person perspective) whilst talking through the reasons for choosing their response. All interviews were audio-recorded and transcribed verbatim. A thematic analysis was used for data analysis.

RESULTS

The sample included 29 proxies; nine family members and 20 aged care staff. The first theme summarised proxies' ability to proxy report residents' health and well-being using the EQ-HWB, which highlighted challenges with adherence to the proxy perspective, proxies' limited knowledge about residents, disagreement with residents' self-evaluation and use of heuristics. The second theme reflected feedback on the suitability of the EQ-HWB for use in residential aged care. Although proxies perceived that the EQ-HWB covered important domains, there were concerns about ambiguity, inappropriate examples, double-barrelled items and perceived repetition. Suggestions were made to improve the response options, comprehensiveness, recall period, layout and instructions of the questionnaire.

CONCLUSIONS

While the EQ-HWB captures domains relevant to residential aged care, modifications to item wording and examples are necessary to improve its appropriateness. Use of the proxy-person perspective revealed some challenges that require further consideration.

Telling Tales: Using Vignettes to Overcome Optimism Bias in Farm Health and Safety Attitudinal Studies

OBJECTIVE

Measuring attitudes of farmers to safe farming practices using quantitative causal relationship approaches is central to improving understanding of (un)safe practices. This knowledge is important in the development of effective farm safety interventions. However, the accuracy of quantitative attitudinal studies in explaining farmers' decision-making faces a potential measurement challenge, i.e. a high level of optimism bias. In this paper, we present research that develops and tests farm safety attitudinal questions that are framed around "real-life" farming practices with the objective of reducing optimism bias.

METHODS

We apply construal level theory (CLT) to support the design of vignettes that reflect common risk scenarios faced by farmers. Applying qualitative analysis of 274 fatal farm incidents that occurred in Ireland between 2004 and 2018 we identify the occupational behaviors (what farmers do), social (who are farmers), spatial (where farming takes place), and temporal (when farming happens) dimensions of risks resulting in most deaths. The results informed subsequent co-design activities with farm safety experts and farm advisors to develop "real-life" scenarios, attitudinal questions, and response options. The questionnaire was piloted and subsequently implemented to collect data from a sample of 381 farmers with either tractors or livestock. The results of the survey were compared to previous attitudinal research on farmer's attitudes to safety in Ireland to establish if there was as follows: i) increased variance in the responses, and ii) a statistically significant difference in the attitudes of respondents compared to the results reported in previous studies.

RESULTS

The findings established that when farmers were provided with real-life scenarios, their responses were less optimistic and more varied, i.e. there was a greater range of responses, compared to previous studies.

CONCLUSION

Applying CTL to the development of attitudinal survey instruments anchors attitudinal questions within farming specific occupational, social, spatial, and temporal contexts. The use of vignettes that draw on real-life scenarios offers the potential for improved design of surveys that seek to understand farmer/worker practices. The results suggest that this approach can improve the measurement of attitudes to farm safety.

Further Evidence of Feasibility, Validity, and Reliability of Quality of Life-Aged Care Consumers: Evidence From Home-Based Care Settings

OBJECTIVES

The Quality of Life-Aged Care Consumers (QOL-ACC) is an aged-care-specific preference-based instrument currently being rolled out in residential care across Australia as part of the aged care Quality Indicator program. This study aimed to provide a comprehensive assessment of the feasibility, reliability, and construct validity of the QOL-ACC in a large national sample of older adults receiving aged care services at home.

METHODS

Older adults receiving in-home aged care services completed a survey including the QOL-ACC, Quality of Care Experience-ACC, adult social care outcome tool, EQ-5D-5L, and 2 global single item measures of health and quality of life. Feasibility was assessed by missing responses (≤5%) and ceiling/floor effects (≤15%). Construct validity was assessed by exploring the relationship between the QOL-ACC and other instruments (convergent validity) and its ability to discriminate varying levels of self-rated health and quality of life (known-group validity).

RESULTS

A total of 802 respondents (mean age, 74.5 ± 6.3 years; 56.0% females) completed the survey. The QOL-ACC had no missing responses, no floor effects, and very low ceiling effect (3.5%) and demonstrated moderate correlation with adult social care outcome tool (r = 0.59, P < .001), EQ-5D-5L (r = 0.65, P < .001), EQ-VAS (r = 0.53, P < .001), and a lower correlation with the QCE-ACC (r = 0.41, P < .001). Respondents with poor self-rated health and quality of life had significantly lower preference-weighted scores on the QOL-ACC.

CONCLUSIONS

The QOL-ACC demonstrated adequate feasibility, reliability, and construct validity in a large population of older people accessing government-subsidized aged care services at home. Further studies will explore the responsiveness of the QOL-ACC to aged-care-specific interventions both in home and residential aged care settings.

Understanding the influence of different proxy perspectives in explaining the difference between self-rated and proxy-rated quality of life in people living with dementia: a systematic literature review and meta-analysis

PURPOSE

Proxy assessment can be elicited via the proxy-patient perspective (i.e., asking proxies to assess the patient's quality of life (QoL) as they think the patient would respond) or proxy-proxy perspective (i.e., asking proxies to provide their own perspective on the patient's QoL). This review aimed to identify the role of the proxy perspective in explaining the differences between self-rated and proxy-rated QoL in people living with dementia.

METHODS

A systematic literate review was conducted by sourcing articles from a previously published review, supplemented by an update of the review in four bibliographic databases. Peer-reviewed studies that reported both self-reported and proxy-reported mean QoL estimates using the same standardized QoL instrument, published in English, and focused on the QoL of people with dementia were included. A meta-analysis was conducted to synthesize the mean differences between self- and proxy-report across different proxy perspectives.

RESULTS

The review included 96 articles from which 635 observations were extracted. Most observations extracted used the proxy-proxy perspective (79%) compared with the proxy-patient perspective (10%); with 11% of the studies not stating the perspective. The QOL-AD was the most commonly used measure, followed by the EQ-5D and DEMQOL. The standardized mean difference (SMD) between the self- and proxy-report was lower for the proxy-patient perspective (SMD: 0.250; 95% CI 0.116; 0.384) compared to the proxy-proxy perspective (SMD: 0.532; 95% CI 0.456; 0.609).

CONCLUSION

Different proxy perspectives affect the ratings of QoL, whereby adopting a proxy-proxy QoL perspective has a higher inter-rater gap in comparison with the proxy-patient perspective.

Comparative analysis of stress level and coping strategies due to COVID-19 pandemics among dental students in Indonesia and Vietnam

Objective

This study investigated and compared the perceived stress levels and coping strategies of dental students in Indonesia and Vietnam during the COVID-19 pandemic.

Materials and methods

A cross-sectional survey was conducted online in 2022 for dental students from the University of Indonesia and Can Tho University, Vietnam (n = 304). Perceived stress levels and coping strategies were assessed using a self-administered questionnaire about student sociodemographic factors, learning experiences, coping strategies, stress-related factors, and stress levels. Data were analyzed using Mann-Whitney, Kruskal Wallis, and Spearman correlation tests.

Results

This study showed the overall mean stress level was 23.9 (SD = 5.63), with a significant difference observed between Indonesian (24.44, SD = 5.14) and Vietnamese students (23.32, SD = 6.13) (p = 0.016), indicating potential variations in stress experiences. Key findings include a correlation between living arrangements and stress, as students living independently report higher stress (23.96, SD = 6.24) compared to those living with family (23.95, SD = 5.29) (p = 0.018). Fifth-year students exhibit lower stress levels (21.17, SD = 6.12) than other grades (p = 0.026). Multiple training sessions about COVID-19 are associated with better coping strategies (9.95, SD = 0.91, p < 0.001). The study also revealed different perceptions of COVID-19 learning experiences among dental students in Indonesian and Vietnamese dental students, with significant correlations observed between stress levels, coping strategies, and specific concerns such as graduation time and COVID-19-induced changes (p < 0.05).

Conclusion

This study shows students experience moderate stress levels, but the significant differences in stress experiences and coping strategies between the two countries highlighted the need for tailored approaches. Providing social support from faculty, family, friends, and peer dental students was one of the students' strategies to cope and minimize stress levels.

Content validity of the EQ-HWB and EQ-HWB-S in a sample of Italian patients, informal caregivers and members of the general public

BACKGROUND

The EuroQol Group recently developed two new instruments, the EQ Health and Wellbeing (EQ-HWB) and the EQ Health and Wellbeing short version (EQ-HWB-S). The EQ-HWB and EQ-HWB-S are intended to capture a broad range of health and broader quality of life aspects, which may be relevant to general public members, patients, their families, social care users and informal carers. This study assesses the content validity of the Italian version of the two instruments in a sample of Italian patients, social care users and informal carers.

METHODS

Participants were recruited using a convenience sampling approach. One-on-one interviews were carried out using video-conferencing interviews. A semi-structured topic guide was used to guide the interview procedures, with open-ended questions supplemented by probes. Participants were asked to explain important aspects of their health and quality of life, to complete the questionnaires and verbalize their thoughts.

RESULTS

Twenty participants comprising of patients (n = 9), informal carers (n = 6), and members of the general public (n = 5) participated to the study. Content validity was summarized into six main themes: comprehension, interpretation, acceptability, relevance, response options and recall period. All participants found the instruments easy or quite easy to understand and to respond to. Items were relevant for all three groups of participants, and response options appropriate.

CONCLUSIONS

The Italian version of the EQ-HWB showed content validity in measuring health and wellbeing in a mixed Italian population.

What Aspects of Quality of Life are Important from Palliative Care Patients' Perspectives? A Framework Analysis to Inform Preference-Based Measures for Palliative and End-of-Life Settings

BACKGROUND AND OBJECTIVE

Preference-based outcome measures are commonly applied in economic analyses to inform healthcare resource allocation decisions. Few preference-based outcome measures have been specifically developed for palliative and end-of-life settings. This study aimed to identify which quality-of-life domains are most important to Australians receiving specialised palliative care services to help determine if the development of a new condition-specific preference-based outcome measure is warranted.

METHODS

In-depth face-to-face interviews were conducted with 18 participants recruited from palliative care services in South Australia. Data were analysed using a framework analysis drawing on findings from a systematic review of international qualitative studies investigating the quality-of-life preferences of patients receiving palliation (domains identified included cognitive, emotional, healthcare, personal autonomy, physical, preparatory, social, spiritual). Participants identified missing or irrelevant domains in the EQ-5D and QLU-C10D questionnaires and ranked the importance of domains.

RESULTS

A priori domains were refined into cognitive, environmental, financial, independence, physical, psychological, social and spiritual. The confirmation of the eight important quality-of-life domains across multiple international studies suggests there is a relatively high degree of convergence on the perspectives of patients in different countries. Four domains derived from the interviews are not covered by the EQ-5D and QLU-C10D (cognitive, environmental, financial, spiritual), including one of the most important (spiritual).

CONCLUSIONS

Existing, popular, preference-based outcome measures such as the EQ-5D do not incorporate the most important, patient-valued, quality-of-life domains in the palliative and end-of-life settings. Development of a new, more relevant and comprehensive preference-based outcome measure could improve the allocation of resources to patient-valued services and have wide applicability internationally.

Feasibility of self-reported health related quality of life assessment with older people in residential care: insights from the application of eye tracking technology

PURPOSE

Increasingly there are calls to routinely assess the health-related quality of life (HRQoL) of older people receiving aged care services, however the high prevalence of dementia and cognitive impairment remains a challenge to implementation. Eye-tracking technology facilitates detailed assessment of engagement and comprehension of visual stimuli, and may be useful in flagging individuals and populations who cannot reliably self-complete HRQoL instruments. The aim of this study was to apply eye-tracking technology to provide insights into self-reporting of HRQoL among older people in residential care with and without cognitive impairment.

METHODS

Residents (n = 41), recruited based on one of three cognition subgroups (no, mild, or moderate cognitive impairment), completed the EQ-5D-5L on a computer with eye tracking technology embedded. Number and length of fixations (i.e., eye gaze in seconds) for key components of the EQ-5D-5L descriptive system were calculated.

RESULTS

For all dimensions, participants with no cognitive impairment fixated for longer on the Area of Interest (AOI) for the response option they finally chose, relative to those with mild or moderate cognitive impairment. Participants with cognitive impairment followed similar fixation patterns to those without. There was some evidence that participants with cognitive impairment took longer to complete and spent relatively less time attending to the relevant AOIs, but these differences did not reach statistical significance generally.

CONCLUSIONS

This exploratory study applying eye tracking technology provides novel insights and evidence of the feasibility of self-reported HRQoL assessments in older people in aged care settings where cognitive impairment and dementia are highly prevalent.

Face Validity of Four Preference-Weighted Quality-of-Life Measures in Residential Aged Care: A Think-Aloud Study

OBJECTIVE

There is an increased use of preference-weighted quality-of-life measures in residential aged care to guide resource allocation decisions or for quality-of-care assessments. However, little is known about their face validity (i.e., how understandable, appropriate and relevant the measures are 'on their face' when respondents complete them). The aim of this study was to assess the face validity of four preference-weighted measures (i.e., EQ-5D-5L, EQ-HWB, ASCOT, QOL-ACC) in older people living in residential aged care.

METHODS

Qualitative cognitive think-aloud interviews were conducted using both concurrent and retrospective think-aloud techniques. To reduce burden, each resident completed two measures, with the four measures randomised across participants. Audio recordings were transcribed and framework analysis was used for data analysis, based on an existing framework derived from the Tourangeau four-stage response model.

RESULTS

In total, 24 interviews were conducted with residents living across three residential aged care facilities in Melbourne, Australia. Response issues were identified across all four measures, often related to comprehension and difficulty selecting a response level due to double-barrelled and ambiguous items that have different meanings in the residential aged care context. We also identified issues related to understanding instructions, non-adherence to the recall period, and noted positive responding that requires attention when interpreting the data.

CONCLUSIONS

Our findings provide further evidence on the appropriateness of existing measures, indicating numerous response issues that require further research to guide the selection process for research and practice.

How do older adults receiving aged care services understand and respond to the EQ-5D-5L? A think-aloud study in residential care

PURPOSE

The EQ-5D-5L is a preference-based instrument for measuring and valuing health-related quality of life (HRQoL). The EQ-5D-5L has been used extensively in economic evaluation, including in aged care. However, older adults' understanding of the EQ-5D-5L has not been comprehensively investigated to date. This research aimed to assess older adults' understanding of the EQ-5D-5L using a think-aloud protocol with two cognition groups: no cognitive impairment and mild/moderate cognitive impairment.

METHODS

Participants' cognition was assessed using the Standardised Mini-Mental State Examination (SMMSE). Face-to face interviews were conducted with concurrent and retrospective think-aloud encouraged through verbal probing. Audio recordings were transcribed, and qualitative analysis, informed by the Tourangeau four-stage Response Model (comprehension, retrieval, decision process, response process) was conducted in NVivo.

RESULTS

In total, 46 older adults (age 65 +) were recruited from 10 residential care facilities across South Australia (n = 25 no cognitive impairment, n = 21 mild/moderate cognitive impairment). Comprehension, retrieval, judgement and response mapping issues were common across all cognition levels and EQ-5D-5L dimensions. The two dimensions resulting in the most response issues were usual activities and personal care.

CONCLUSION

Older adults may bring a different understanding to the EQ-5D-5L descriptive system than that expected given testing with general population samples. Dimension descriptors that are more relevant to this population may facilitate responses that better align with the underlying EQ-5D-5L concept model.

The Feasibility and Validity of Preference-Based Quality of Life Measures With Informal Carers: A Think-Aloud Study

OBJECTIVES

A range of preference-based quality of life (QoL) measures have been proposed for use with informal carers. Qualitative evaluation of validity and feasibility of the measures is an important step in understanding whether measures will work as intended. At present, little is known about the performance of different types of preference-based QoL measures with informal carers. The objective of this study was to qualitatively assess the feasibility, content validity (including face validity), and acceptability of 5 QoL measures (the Carer Experience Scale, CarerQoL-7D, ASCOT-C, ICECAP-A, and EQ-5D-5L) with informal carers.

METHODS

A total of 24 "think-aloud" interviews were conducted with a cross-section of carers of adults in the United Kingdom. This think-aloud process was followed by semistructured discussion to probe issues of validity and feasibility in more detail. The interview data were transcribed, coded to identify the frequency of errors in completing the QoL measures and thematically analyzed to study the validity, feasibility, and acceptability of the measures.

RESULTS

Few errors (3%-7% per item) were identified in completing each of the measures with little distinct pattern. Most participants found the measures to be concise, clear, and relevant. Challenges included relevance, context, time period, missing items, multiple questions, and response options. Informal carers generally expressed a preference for using a care-related QoL measure.

CONCLUSIONS

Existing preference-based QoL measures have encouraging validity and feasibility within a mixed sample of informal carers, with minor challenges raised. These challenges ought to be considered, alongside the decision context, when administering QoL measures in this context.

Do social influences, awareness, or experience matter? Toward a better understanding of Farm-related Injury Risk Perception among agricultural science college students in Ireland

Introduction

Formal farm safety education/training should be tailored, in terms of the approach, content and delivery, to students undertaking agriculture education and training to enhance Farm-related Injury Risk Perception (FIRP). To this end, this paper assesses factor(s) explaining or predicting levels of FIRP amongst students studying for a degree in agriculture science.

Methods

A cross-sectional online survey was conducted with a nationally representative sample of Bachelor of Agriculture Science (BAgrSc) students (N = 417) (aged 18-20) in Ireland. Descriptive [frequency and cross-tabulations) and inferential (Ordinal Logistic Regression (OLR)] analyses were applied to evaluate the effects of social influences, experience (of farming, of a near-miss or injury), and awareness (of others who were injured or killed on the farm) on FIRP.

Results

The study found that social influences negatively affected FIRP (P < 0.05). A relatively small number of students reported experiencing an injury (n = 56, 13.4%) that resulted in them being unable to participate in educational or social activities. A quarter of the respondents did, however, record experiencing a near-miss/close call (n = 106, 25.4%). A notable proportion (n = 144, 34.5%) of students had personal connections to someone who died as a consequence of a farm-related incident and 56.4% (n = 235) knew someone who was moderately or severely injured. OLR findings established that experiencing a severe injury, having a near-miss or close call, and awareness of a farm-related death or injury positively affects FIRP (P < 0.05).

Conclusions

Perception of farm risks amongst students in Ireland is low. Students who recorded higher levels of risk perception were, however, more likely to report experiencing a near-miss, close call or severe injury, or knowing someone who experienced a farm-related injury or fatality. Farmers, family or friends were found to negatively impact the FIRP and this reflects previous research findings. Our findings highlight the need for education and training programs to enhance opportunities for student peer-to-peer learning through sharing of experiences and/or knowledge of farm injuries and/or fatalities. Such activities will enhance awareness and understanding amongst the general population of students leading to increased FIRP and contribute to a reduction in risk-taking.

A Qualitative Investigation of Older Adults' Conceptualization of Quality of Life and a Think-Aloud Content Validation of the EQ-5D-5L, SF-12v2, Warwick Edinburgh Mental Wellbeing Scale, and Office of National Statistics-4

OBJECTIVES

Old age is characterized by declining health, comorbidities, and increasing health and social care service use. Traditionally, patient-reported outcome measures (PROMs) including the EQ-5D-5L and SF-12v2 have focused on health. Nevertheless, aged care often aims to improve broader elements of quality of life (QoL), captured by well-being measures, such as the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS) and Office of National Statistics-4 (ONS-4). This study investigates older adults' conceptualization of QoL and the content validity of the EQ-5D-5L, SF-12v2, WEMWBS, and ONS-4 in measuring their QoL.

METHODS

Qualitative cognitive think-aloud interviews were undertaken with older adults aged 75+, exploring their views on what was important to QoL and, for each measure, the relevance, acceptability, and interpretation of items; suitability of response options; and the comprehensiveness of the measure. Conceptualization of QoL was analyzed thematically and content validity using framework analysis.

RESULTS

Twenty interviews were undertaken. Older adults' conceptualization of QoL centered on health, ability to perform usual activities, social contact, and emotional functioning. Possible response shift was observed, as older adults assessed their health relative to lower health expectations at their age or to people in worse states. Participants questioned the relevance of negatively phrased mental items and often preferred the functioning-focused EQ-5D-5L to more subjective ONS-4 and WEMWBS items. Domains suggested to improve comprehensiveness included social contact, coping, security, dignity, and control.

CONCLUSIONS

These findings are useful to researchers developing new PROMs for older adults or for the developers of included PROMs considering permanently adapting or bolting-on domains to improve content validity in older adults.

Assessing the psychometric performance of EQ-5D-5L in dementia: a systematic review

BACKGROUND

EQ-5D is widely used for valuing changes in quality of life for economic evaluation of interventions for people with dementia. There are concerns about EQ-5D-3L in terms of content validity, poor inter-rater agreement and reliability in the presence of cognitive impairment, but there is also evidence to support its use with this population. An evidence gap remains regarding the psychometric properties of EQ-5D-5L.

OBJECTIVES

To report psychometric evidence around EQ-5D-5L in people with dementia.

METHODS

A systematic review identified primary studies reporting psychometric properties of EQ-5D-5L in people with dementia. Searches were completed up to November 2020. Study selection, data extraction and quality assessment were undertaken independently by at least 2 researchers.

RESULTS

Evidence was extracted from 20 articles from 14 unique studies covering a range of dementia severity. Evidence of known group validity from 5 of 7 studies indicated that EQ-5D-5L distinguishes severity of disease measured by cognitive impairment, depression, level of dependence and pain. Convergent validity (9 studies) showed statistically significant correlations of weak and moderate strengths, between EQ-5D-5L scores and scores on other key measures. Statistically significant change was observed in only one of 6 papers that allowed this property to be examined. All seven studies showed a lack of inter-rater reliability between self and proxy reports with the former reporting higher EQ-5D-5L scores than those provided by proxies. Five of ten studies found EQ-5D-5L to be acceptable, assessed by whether the measure could be completed by the PwD and/or by the amount of missing data. As dementia severity increased, the feasibility of self-completing EQ-5D-5L decreased. Three papers reported on ceiling effects, two found some evidence in support of ceiling effects, and one did not.

CONCLUSIONS

EQ-5D-5L seems to capture the health of people with dementia on the basis of known-group validity and convergent validity, but evidence is inconclusive regarding the responsiveness of EQ-5D-5L. As disease progresses, the ability to self-complete EQ-5D-5L is diminished.

Validation of a COVID-19 mental health and wellness survey questionnaire

BACKGROUND AND AIM

COVID-19 affected mental health and wellbeing. Research is needed to assess its impact using validated tools. The study assessed the content validity, reliability and dimensionality of a multidimensional tool for assessing the mental health and wellbeing of adults.

METHODS

An online questionnaire collected data in the second half of 2020 from adults in different countries. The questionnaire included nine sections assessing: COVID-19 experience and sociodemographic profile; health and memory; pandemic stress (pandemic stress index, PSI); financial and lifestyle impact; social support; post-traumatic stress disorder (PTSD); coping strategies; self-care and HIV profile over 57 questions. Content validity was assessed (content validity index, CVI) and participants evaluated the test-retest reliability (Kappa statistic and intra-class correlation coefficient, ICC). Internal consistency of scales was assessed (Cronbach α). The dimensionality of the PSI sections and self-care strategies was assessed by multiple correspondence analysis (MCA) using all responses and SPSS. For qualitative validation, we used a semi-structured interview and NVivo was used for coding and thematic analysis.

RESULTS

The overall CVI = 0.83 with lower values for the memory items. Cronbach α for the memory items = 0.94 and ICC = 0.71. Cronbach α for PTSD items was 0.93 and ICC = 0.89. Test-retest scores varied by section. The 2-dimensions solution of MCA for the PSI behavior section explained 33.6% (precautionary measures dimension), 11.4% (response to impact dimension) and overall variance = 45%. The 2-dimensions of the PSI psychosocial impact explained 23.5% (psychosocial impact of the pandemic dimension), 8.3% (psychosocial impact of the precautionary measures of the pandemic dimension) and overall variance = 31.8%. The 2-dimensions of self-care explained 32.9% (dimension of self-care strategies by people who prefer to stay at home and avoid others), 9% (dimension of self-care strategies by outward-going people) and overall variance = 41.9%. Qualitative analysis showed that participants agreed that the multidimensional assessment assessed the effect of the pandemic and that it was better suited to the well-educated.

CONCLUSION

The questionnaire has good content validity and can be used to assess the impact of the pandemic in cross-sectional studies especially as individual items. The PSI and self-care strategies need revision to ensure the inclusion of items with strong discrimination.

Examining Face Validity of Visual Stimuli Used in Preference Assessments for Older Adults With Communication Impairments

PURPOSE

Preference assessment is integral to person-centered treatment planning for older adults with communication impairments. There is a need to validate photographs used in preference assessment for this population. Therefore, this study aimed to establish preliminary face validity of photographs selected to enhance comprehension of questions from the Preferences for Everyday Living Inventory-Nursing Home (PELI-NH) and describe themes in older adults' recommendations for revising photographic stimuli.

METHOD

This qualitative, cognitive interviewing study included 21 participants with an average age of 75 years and no known cognitive or communication deficits. Photographic stimuli were randomized and evaluated across one to two interview sessions. Participants were asked to describe what the preference stimuli represented to them. Responses were scored to assess face validity. Participants were then shown the PELI-NH written prompt and asked to evaluate how well the photograph(s) represented the preference. A semideductive thematic analysis was conducted on interview transcripts to summarize themes in participant feedback.

RESULTS

Forty-six (64%) stimuli achieved face validity criteria without revisions. Six (8%) stimuli achieved face validity after one partial revision. Twenty (28%) stimuli required multiple revisions and reached feedback saturation, requiring team review for finalization. Thematic analysis revealed challenges interpreting stimuli (e.g., multiple meanings) and participant preferences for improving photographs (e.g., aesthetics).

CONCLUSIONS

Cognitive interviewing was useful for improving face validity of stimuli pertaining to personal care topics. Abstract and subjective preferences (e.g., cultural traditions) may be more challenging to represent. This study provides a framework for further testing with older adults with cognitive, communication, and hearing impairments.

A multidomain decision support tool to prevent falls in older people: the FinCH cluster RCT

BACKGROUND

Falls in care home residents are common, unpleasant, costly and difficult to prevent.

OBJECTIVES

The objectives were to evaluate the clinical effectiveness and cost-effectiveness of the Guide to Action for falls prevention in Care Homes (GtACH) programme.

DESIGN

A multicentre, cluster, parallel, 1 : 1 randomised controlled trial with embedded process evaluation and economic evaluation. Care homes were randomised on a 1 : 1 basis to the GtACH programme or usual care using a secure web-based randomisation service. Research assistants, participating residents and staff informants were blind to allocation at recruitment; research assistants were blind to allocation at follow-up. NHS Digital data were extracted blindly.

SETTING

Older people's care homes from 10 UK sites.

PARTICIPANTS

Older care home residents.

INTERVENTION

The GtACH programme, which includes care home staff training, systematic use of a multidomain decision support tool and implementation of falls prevention actions, compared to usual falls prevention care.

OUTCOMES

The primary trial outcome was the rate of falls per participating resident occurring during the 90-day period between 91 and 180 days post randomisation. The primary outcome for the cost-effectiveness analysis was the cost per fall averted, and the primary outcome for the cost-utility analysis was the incremental cost per quality adjusted life-year. Secondary outcomes included the rate of falls over days 0-90 and 181-360 post randomisation, activity levels, dependency and fractures. The number of falls per resident was compared between arms using a negative binomial regression model (generalised estimating equation).

RESULTS

A total of 84 care homes were randomised: 39 to the GtACH arm and 45 to the control arm. A total of 1657 residents consented and provided baseline measures (mean age 85 years, 32% men). GtACH programme training was delivered to 1051 staff (71% of eligible staff) over 146 group sessions. Primary outcome data were available for 630 GtACH participants and 712 control participants. The primary outcome result showed an unadjusted incidence rate ratio of 0.57 (95% CI 0.45 to 0.71; p < 0.01) in favour of the GtACH programme. Falls rates were lower in the GtACH arm in the period 0-90 days. There were no other differences between arms in the secondary outcomes. Care home staff valued the training, systematic strategies and specialist peer support, but the incorporation of the GtACH programme documentation into routine care home practice was limited. No adverse events were recorded. The incremental cost was £20,889.42 per Dementia Specific Quality of Life-based quality-adjusted life-year and £4543.69 per quality-adjusted life-year based on the EuroQol-5 dimensions, five-level version. The mean number of falls was 1.889 (standard deviation 3.662) in the GtACH arm and 2.747 (standard deviation 7.414) in the control arm. Therefore, 0.858 falls were averted. The base-case incremental cost per fall averted was £190.62.

CONCLUSION

The GtACH programme significantly reduced the falls rate in the study care homes without restricting residents' activity levels or increasing their dependency, and was cost-effective at current thresholds in the NHS.

FUTURE WORK

Future work should include a broad implementation programme, focusing on scale and sustainability of the GtACH programme.

LIMITATIONS

A key limitation was the fact that care home staff were not blinded, although risk was small because of the UK statutory requirement to record falls in care homes.

TRIAL REGISTRATION

This trial is registered as ISRCTN34353836.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 9. See the NIHR Journals Library website for further project information.