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Elsman EBM, Smith M, Hofstetter C, Gavin F, Jobson E, Markham S, Ricketts J, Baba A, Butcher NJ, Offringa M. A blueprint for patient and public involvement in the development of a reporting guideline for systematic reviews of outcome measurement instruments: PRISMA-COSMIN for OMIs 2024. Res Involv Engagem 2024; 10:33. [PMID: 38515153 PMCID: PMC10956212 DOI: 10.1186/s40900-024-00563-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/12/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND In recent years, projects to develop reporting guidelines have attempted to integrate the perspectives of patients and public members. Best practices for patient and public involvement (PPI) in such projects have not yet been established. We recently developed an extension of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), to be used for systematic reviews of outcome measurement instruments (OMIs): PRISMA-COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) for OMIs 2024. Patients and public members formed a small but impactful stakeholder group. We critically evaluated the PPI component in this project and developed recommendations for conducting PPI when developing reporting guidelines. MAIN TEXT A patient partner was an integral research team member at the project development and grant application stage. Once the project started, five patient and public contributors (PPCs) were recruited to participate in the Delphi study; three PPCs contributed to subsequent steps. We collected quantitative feedback through surveys; qualitative feedback was garnered through a focus group discussion after the Delphi study and through debrief meetings after subsequent project activities. Feedback was thematically combined with reflections from the research team, and was predominantly positive. The following themes emerged: importance of PPI partnership, number of PPCs involved, onboarding, design of Delphi surveys, flexibility in the process, complexity of PPI in methodological research, and power imbalances. Impacts of PPI on the content and presentation of the reporting guideline were evident, and reciprocal learning between PPCs and the research team occurred throughout the project. Lessons learned were translated into 17 recommendations for future projects. CONCLUSION Integrating PPI in the development of PRISMA-COSMIN for OMIs 2024 was feasible and considered valuable by PPCs and the research team. Our approach can be applied by others wishing to integrate PPI in developing reporting guidelines.
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Affiliation(s)
- Ellen B M Elsman
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
- Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Epidemiology & Data Science, Amsterdam, Netherlands
| | - Maureen Smith
- Patient Partner, Cochrane Consumer Network, Ottawa, ON, Canada
| | - Catherine Hofstetter
- Patient and Public Contributor/Advisor, OMERACT Patient Research Partner, Toronto, ON, Canada
| | - Frank Gavin
- Patient and Public Contributor, Chair of the Public Advisory Council of The Health Data Research Network (Canada), Toronto, ON, Canada
| | - Estelle Jobson
- Patient and Public Contributor, EUPATI Fellow, Nyon, Switzerland
| | - Sarah Markham
- Patient and Public Contributor, King's College London, London, UK
| | | | - Ami Baba
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Nancy J Butcher
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON, Canada.
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
- Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada.
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Adhikari S, van Nispen RMA, Poudel M, van Rens F, Elsman EBM, van der Werf YD, van Rens GHMB. Sleep Patterns in Children With Blindness: A Comparison With Normally Sighted Peers. Invest Ophthalmol Vis Sci 2023; 64:46. [PMID: 38032337 PMCID: PMC10691385 DOI: 10.1167/iovs.64.14.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose Studies showing problematic sleep patterns in blind and visually impaired children are often based on (parent) self-report. The purpose was to compare sleep patterns of blind children to normally sighted peers using objective measures. Methods In this cross-sectional study, 100 blind (best-corrected visual acuity <3/60) and 100 age- and gender-matched normally sighted children aged 7 to 17 years wore a digital activity monitoring device for 1 week. Sleep quantity (i.e., total sleep time and total time in bed) and sleep quality (number of awakenings, latency, efficiency, wake after sleep onset [WASO], and sleep fragmentation index) were measured. Adjusted linear regression analyses were used to model group differences in sleep parameters. Results Data of 163 children were included. Blind children spent significantly less total time in bed in minutes (β, -31; 95% confidence interval, -56 to -6) and had a lower total sleep time (-41; -66 to -17), smaller number of awakenings (-2.8; -4.5 to -1.0), a lower WASO (-10; -16 to -5), and a more efficient sleep pattern (1.5; 0.1 to 2.8) compared to normally sighted children. Conclusions Although sleep quantity and recommended hours of sleep per night were lower among blind children than normally sighted children, their sleep quality was better. This contradicts findings of self-report studies and warrants further studies to measure sleep objectively. Further, the discrepancy between previous findings and our findings regarding sleep quality may be explained by the house rules of the boarding schools attended by blind children, which may facilitate improved sleep hygiene.
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Affiliation(s)
- Srijana Adhikari
- Tilganga Institute of Ophthalmology, Gaushala, Kathmandu, Nepal
- Amsterdam UMC, Vrije Universiteit, Department of Ophthalmology, Amsterdam, The Netherlands
- Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands
| | - Ruth M. A. van Nispen
- Amsterdam UMC, Vrije Universiteit, Department of Ophthalmology, Amsterdam, The Netherlands
- Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands
| | - Manish Poudel
- Tilganga Institute of Ophthalmology, Gaushala, Kathmandu, Nepal
| | - Fleur van Rens
- Discipline of Exercise Science, Murdoch University, Murdoch, Australia
| | - Ellen B. M. Elsman
- Amsterdam UMC, Vrije Universiteit, Department of Ophthalmology, Amsterdam, The Netherlands
- Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands
| | - Ysbrand D. van der Werf
- Amsterdam UMC, Vrije Universiteit, Department of Anatomy and Neuroscience, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Compulsivity Impulsivity and Attention, Amsterdam, The Netherlands
| | - Ger H. M. B. van Rens
- Amsterdam UMC, Vrije Universiteit, Department of Ophthalmology, Amsterdam, The Netherlands
- Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands
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Baba A, Richards DP, Smith M, Pallone N, Vanderhout S, Prebeg M, Elsman EBM, Potter BK, Offringa M, Butcher NJ. Youth and family involvement in the development of a plain language trial results communication tool: CommuniKIDS. Res Involv Engagem 2023; 9:88. [PMID: 37777802 PMCID: PMC10544151 DOI: 10.1186/s40900-023-00499-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/25/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Pediatric trials are possible through voluntary participation of children, youth (age ≤ 18 years), and their families. Despite important arguments for trialists to provide trial progress or results, and evidence that participants desire it, this information remains rarely shared with youth and their families. Little guidance exists on how trialists can best communicate trial results back to participants and their families. Guided by Liabo et al.'s framework, we describe how we developed a pediatric-specific, "plain language summary" clinical trial results template called CommuniKIDS with an adult patient partner, family partner (parent), youth advisors, and parent advisors, taking into account their unique knowledge needs and preferences. MAIN TEXT Patient and Public Involvement (PPI) was integrated in the development of the CommuniKIDS template. In collaboration with Clinical Trials Ontario, we used a generic trial results template as a starting point. The core project leadership team included a patient partner and a family partner from project inception to completion. Five youth (ages 13-18 years) and eight parent advisors were consulted at each point of the development process through three virtual workshops conducted separately; youth workshops were led by a youth facilitator. During these workshops, advisors agreed on the importance and value of sharing trial results, and expressed their preferences on content, format, and timing of sharing trial results. PPI-led improvements included the addition of three new sections to the CommuniKIDS template: "at a glance," "side effects," and "next steps." We reflect on our PPI strategy in the context of five "values" and six "practicalities" identified as good PPI principles, and summarize lessons learned when collaborating with youth and families from this project. CONCLUSION Involvement of a patient partner, a family partner, youth advisors, and parent advisors in the development of CommuniKIDS was critical to create a clinical trial results template that is useful and relevant to its end-users. To our knowledge, CommuniKIDS is the first to meaningfully engage youth and parents as advisors and partners in developing a plain language summary results template for pediatric trial participants and their families. Our experience of co-developing CommuniKIDS demonstrates that meaningful PPI can be achieved in trial results communication and knowledge translation practices. This report provides resources for those seeking to involve youth and families in their initiatives and in meaningfully sharing trial results.
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Affiliation(s)
- Ami Baba
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | | | - Maureen Smith
- Canadian Organization for Rare Disorders, Ottawa, ON, Canada
| | - Nicole Pallone
- CanPKU and Parent of a Child with an Inherited Metabolic Disease, Sparwood, BC, Canada
| | - Shelley Vanderhout
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Matthew Prebeg
- Department of Psychiatry, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ellen B M Elsman
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Beth K Potter
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
- Division of Neonatology, The Hospital for Sick Children, Toronto, ON, Canada.
- Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada.
| | - Nancy J Butcher
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON, Canada.
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
- Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada.
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Stallwood E, Elsman EBM, Monsour A, Baba A, Butcher NJ, Offringa M. Measurement Properties of Patient Reported Outcome Scales: A Systematic Review. Pediatrics 2023:e2023061489. [PMID: 37439131 DOI: 10.1542/peds.2023-061489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 07/14/2023] Open
Abstract
CONTEXT Recently a standard set for overall pediatric health outcomes in routine care was developed, which includes patient (or proxy) reported outcome measures (PROMs) for global health, cognitive functioning, and self-efficacy. OBJECTIVES To determine whether the following PROMs have sufficient measurement properties to be used in pediatric routine care: PROMIS Pediatric and Parent Proxy Scale - Global Health 7+2, PROMIS Parent Proxy Short Form - Cognitive Function 7a, and NIH Toolbox Self-Efficacy CAT Ages 13 to 17. DATA SOURCES Embase, Psych INFO, and Web of Science were searched from year of inception of each PROM to May 25, 2020; Medline to October 24, 2022. STUDY SELECTION English, full-text peer-reviewed articles that evaluated measurement properties of included PROMs were eligible. DATA EXTRACTION The COSMIN guideline for systematic reviews was used to appraise eligible studies and synthesize the overall evidence. RESULTS Screening >4000 titles yielded 4 to 6 eligible empirical studies for each PROM. The PROMIS instruments had sufficient content validity with low-quality evidence and at least low-quality evidence for sufficient structural validity and internal consistency. The NIH Toolbox lacked essential evidence for content validity. LIMITATIONS Assessments of measurement properties were based on information reported in the included studies; underreporting might have led to less favorable ratings. CONCLUSIONS The PROMIS instruments assessed in this review measure their intended construct for their targeted age group; clinicians can use these PROMs in pediatric routine care. Additional studies evaluating measurement properties, including content validity, are needed for the NIH Toolbox before it should be recommended for use in clinical practice.
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Affiliation(s)
- Emma Stallwood
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Ellen B M Elsman
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Andrea Monsour
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Ami Baba
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Nancy J Butcher
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; and
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Terwee CB, van Litsenburg RRL, Elsman EBM, Roorda LD. Psychometric properties and reference values of the Patient-Reported Outcomes Measurement Information System (PROMIS) sleep item banks in the Dutch general population. J Sleep Res 2023; 32:e13753. [PMID: 36254358 DOI: 10.1111/jsr.13753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/29/2022] [Accepted: 09/21/2022] [Indexed: 11/29/2022]
Abstract
Psychometric properties of the v1.0 Patient-Reported Outcomes Measurement Information System (PROMIS®) sleep disturbance (27 items) and sleep-related impairment (SRI; 16 items) item banks, short forms derived from the item bank, and simulated computerised adaptive test (CAT), were assessed in a representative sample of 1,006 adults from the Dutch general population. For sleep disturbance all items fitted the item response theory model. Four items showed differential item functioning (i.e., lack of measurement invariance) for age and two for language but the impact on scores (expressed as T-scores) was small. Reliable scores (r > 0.90) were found for 92.2%-96.3% of respondents with the full bank, short forms with six and eight items, and CAT, but for only 25.6% with the four-item short form. For SRI two items did not fit the item response theory model. Four items showed differential item functioning for language but the impact on T-scores was small. Reliable scores were found for 82.1% with the full bank, for 47.8%-69.5% with short forms and CAT. T-scores of 49.7 and 49.3 represent the average score of the Dutch general population for sleep disturbance and SRI, respectively. In conclusion, sufficient structural validity, reliability, and cross-cultural validity was found for the full banks but short forms of four items are not reliable enough for clinical practice. For SRI we recommend the full item bank if this is the primary outcome.
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Affiliation(s)
- Caroline B Terwee
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Epidemiology and Data Science, Amsterdam, the Netherlands.,Amsterdam Public Health, Methodology, Amsterdam, the Netherlands
| | | | - Ellen B M Elsman
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Epidemiology and Data Science, Amsterdam, the Netherlands
| | - Leo D Roorda
- Amsterdam Rehabilitation Research Center
- Reade, Amsterdam, the Netherlands
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Elsman EBM, Lee SQ, van der Aa HPA, van Nassau F, Wisse RPL, Maarsingh OR, Keunen JEE, van Rens GHMB, van Nispen RMA. The evaluation of an online nurse-assisted eye-screening tool in older adults receiving home healthcare. Ophthalmic Physiol Opt 2023. [PMID: 36807604 DOI: 10.1111/opo.13110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/22/2023]
Abstract
PURPOSE To investigate the agreement between an online nurse-assisted eye-screening tool and reference tests in older adults receiving home healthcare and to collect user experiences. METHODS Older adults (65+) receiving home healthcare were included. Home healthcare nurses assisted in administering the eye-screening tool at participants' homes. Approximately 2 weeks later, a researcher administered reference tests at participants' homes. Experiences from participants and home healthcare nurses were collected. Agreement in outcomes (distance and near visual acuity, with the latter being measured using two different optotypes, and macular problems) between the eye-screening tool and reference clinical testing was compared. A difference of less than ±0.15 logMAR was considered acceptable. RESULTS A total of 40 participants were included. Here, we describe the results for the right eye; results for the left eye were similar. The mean difference between the eye-screening tool and reference tests for distance visual acuity was 0.02 logMAR. The mean difference between the eye-screening tool and reference tests using two different optotypes for near visual acuity was 0.06 and 0.03 logMAR, respectively. The majority of the individual data points were within the ±0.15 logMAR threshold (75%, 51% and 58%, respectively). The agreement between tests for macular problems was 75%. Participants and home healthcare nurses were generally satisfied with the eye-screening tool, although remarks for further improvements were made. CONCLUSIONS The eye-screening tool is promising for nurse-assisted eye screening in older adults receiving home healthcare, with the mostly satisfactory agreement. After implementing the eye-screening tool in practice, cost-effectiveness needs to be investigated.
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Affiliation(s)
- Ellen B M Elsman
- Ophthalmology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Quality of Care, Amsterdam Public Health, Amsterdam, the Netherlands
| | - Shan Qi Lee
- Ophthalmology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Hilde P A van der Aa
- Ophthalmology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Health Behaviors & Chronic Diseases, Amsterdam Public Health, Amsterdam, the Netherlands
| | - Femke van Nassau
- Health Behaviors & Chronic Diseases, Amsterdam Public Health, Amsterdam, the Netherlands.,Public and Occupational Health, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - Otto R Maarsingh
- General Practice, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Aging & Later Life, Amsterdam Public Health, Amsterdam, the Netherlands
| | | | - Ger H M B van Rens
- Ophthalmology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ruth M A van Nispen
- Ophthalmology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Quality of Care, Amsterdam Public Health, Amsterdam, the Netherlands
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Terwee CB, Elders PJM, Langendoen-Gort M, Elsman EBM, Prinsen CAC, van der Heijden AA, de Wit M, Beulens JWJ, Mokkink LB, Rutters F. Content Validity of Patient-Reported Outcome Measures Developed for Assessing Health-Related Quality of Life in People with Type 2 Diabetes Mellitus: a Systematic Review. Curr Diab Rep 2022; 22:405-421. [PMID: 35819705 PMCID: PMC9355936 DOI: 10.1007/s11892-022-01482-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW We aimed to systematically evaluate the content validity of patient-reported outcome measures (PROMs) specifically developed to measure (aspects of) health-related quality of life (HRQOL) in people with type 2 diabetes. A systematic review was performed in PubMed and Embase of PROMs measuring perceived symptoms, physical function, mental function, social function/participation, and general health perceptions, and that were validated to at least some extent. Content validity (relevance, comprehensiveness, and comprehensibility) was evaluated using COSMIN methodology. RECENT FINDINGS We identified 54 (different versions of) PROMs, containing 150 subscales. We found evidence for sufficient content validity for only 41/150 (27%) (subscales of) PROMs. The quality of evidence was generally very low. We found 66 out of 150 (44%) (subscales of) PROMs with evidence for either insufficient relevance, insufficient comprehensiveness, or insufficient comprehensibility. For measuring diabetes-specific symptoms, physical function, mental function, social function/participation, and general health perceptions, we identified one to 11 (subscales of) PROMs with sufficient content validity, although quality of the evidence was generally low. For measuring depressive symptoms, no PROM with sufficient content validity was identified. For each aspect of HRQL, we found at least one PROM with sufficient content validity, except for depressive symptoms. The quality of the evidence was mostly very low.
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Affiliation(s)
- Caroline B Terwee
- Amsterdam UMC, Department of Epidemiology and Data Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands.
| | - Petra J M Elders
- Amsterdam UMC, Department of General Practice, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Marlous Langendoen-Gort
- Amsterdam UMC, Department of General Practice, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Ellen B M Elsman
- Amsterdam UMC, Department of Epidemiology and Data Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Cecilia A C Prinsen
- Amsterdam UMC, Department of Epidemiology and Data Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Amber A van der Heijden
- Amsterdam UMC, Department of General Practice, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Maartje de Wit
- Amsterdam UMC, Department of Medical Psychology, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Joline W J Beulens
- Amsterdam UMC, Department of Epidemiology and Data Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Lidwine B Mokkink
- Amsterdam UMC, Department of Epidemiology and Data Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Femke Rutters
- Amsterdam UMC, Department of Epidemiology and Data Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
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Elsman EBM, Flens G, de Beurs E, Roorda LD, Terwee CB. Towards standardization of measuring anxiety and depression: Differential item functioning for language and Dutch reference values of PROMIS item banks. PLoS One 2022; 17:e0273287. [PMID: 35998333 PMCID: PMC9398458 DOI: 10.1371/journal.pone.0273287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/05/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction The outcomes anxiety and depression are measured frequently by healthcare providers to assess the impact of a disease, but with numerous instruments. PROMIS item banks provide an opportunity for standardized measurement. Cross-cultural validity of measures and the availability of reference values are prerequisites for standardized measurement. Methods PROMIS Anxiety and Depression item banks were completed by 1002 representative Dutch persons. To evaluate cross-cultural validity, data from US participants in PROMIS wave 1 were used and differential item functioning (DIF) was investigated, using an iterative hybrid of logistic regression and item response theory. McFadden’s pseudo R2-change of 2% was the critical threshold. The impact of any DIF on full item banks and short forms was investigated. To obtain Dutch reference values, T-scores for anxiety and depression were calculated for the complete Dutch sample, and age-group and gender subpopulations. Thresholds corresponding to normal limits, mild, moderate and severe symptoms were computed. Results In both item banks, two items had DIF but with minimal impact on population level T-scores for full item banks and short forms. The Dutch general population had a T-score of 49.9 for anxiety and 49.6 for depression, similar to the T-scores of 50.0 of the US general population. T-scores for age-group and gender subpopulations were also similar to T-scores of the US general population. Thresholds for mild, moderate and severe anxiety and depression were set to 55, 60 and 70, identical to US thresholds. Conclusions The limited number of items with DIF and its minimal impact, enables the use of standard (US) item parameters and comparisons of scores between Dutch and US populations. The Dutch reference values provide an important tool for healthcare professionals and researchers to evaluate and interpret symptoms of anxiety and depression, stimulating the uptake of PROMIS measures, and contributing to standardized outcome measurement.
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Affiliation(s)
- Ellen B. M. Elsman
- Department of Epidemiology and Data Science, Amsterdam UMC, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Gerard Flens
- Alliance for Quality in Mental Health Care, Utrecht, The Netherlands
| | - Edwin de Beurs
- Arkin GGZ, Amsterdam, The Netherlands
- Clinical Psychology, Faculty of Social Sciences, Leiden University, Amsterdam, The Netherlands
| | - Leo D. Roorda
- Amsterdam Rehabilitation Research Center | Reade, Amsterdam, The Netherlands
| | - Caroline B. Terwee
- Department of Epidemiology and Data Science, Amsterdam UMC, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- * E-mail:
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Elsman EBM, Roorda LD, Smidt N, de Vet HCW, Terwee CB. Measurement properties of the Dutch PROMIS-29 v2.1 profile in people with and without chronic conditions. Qual Life Res 2022; 31:3447-3458. [PMID: 35751760 PMCID: PMC9587921 DOI: 10.1007/s11136-022-03171-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate the structural validity, internal consistency, measurement invariance, and construct validity of the Dutch PROMIS-29 v2.1 profile, including seven physical (e.g., pain, physical function), mental (e.g., depression, anxiety), and social (e.g., role functioning) domains of health, in a Dutch general population sample including subsamples with and without chronic diseases. METHODS The PROMIS-29 was completed by 63,602 participants from the Lifelines cohort study. Structural validity of the PROMIS-29, including unidimensionality of each domain and the physical and mental health summary scores, was evaluated using factor analyses (criteria: CFI ≥ 0.95, TLI ≥ 0.95, RMSEA ≤ 0.06, SRMR ≤ 0.08). Internal consistency, measurement invariance (no differential item functioning (DIF) for age, gender, administration mode, educational level, ethnicity, chronic diseases), and construct validity (hypotheses on known-groups validity and correlations between domains) were assessed per domain. RESULTS The factor structure of the seven domains was supported (CFI = 0.994, TLI = 0.993, RMSEA = 0.046, SRMR = 0.031) as was unidimensionality of each domain, both in the entire sample and the subsamples. Model fit of the physical and mental health summary scores reached the criteria, and scoring coefficients were obtained. Cronbach's alpha for the seven PROMIS-29 domains ranged from 0.75 to 0.96 in the complete sample. No DIF was detected. Of the predefined hypotheses, 78% could be confirmed. CONCLUSION Sufficient structural validity, internal consistency and measurement invariance were found, both in the entire sample and in subsamples with and without chronic diseases. Requirements for sufficient evidence for construct validity were (almost) met for most subscales. Future studies should investigate test-retest reliability, measurement error, and responsiveness of the PROMIS-29.
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Affiliation(s)
- Ellen B M Elsman
- Department of Epidemiology and Data Science, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands
| | - Leo D Roorda
- Amsterdam Rehabilitation Research Center | Reade, Amsterdam, The Netherlands
| | - Nynke Smidt
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Henrica C W de Vet
- Department of Epidemiology and Data Science, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands
| | - Caroline B Terwee
- Department of Epidemiology and Data Science, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands.
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10
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Elsman EBM, Butcher NJ, Mokkink LB, Terwee CB, Tricco A, Gagnier JJ, Aiyegbusi OL, Barnett C, Smith M, Moher D, Offringa M. Study protocol for developing, piloting and disseminating the PRISMA-COSMIN guideline: a new reporting guideline for systematic reviews of outcome measurement instruments. Syst Rev 2022; 11:121. [PMID: 35698213 PMCID: PMC9195229 DOI: 10.1186/s13643-022-01994-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/28/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Systematic reviews of outcome measurement instruments are important tools in the evidence-based selection of these instruments. COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) has developed a comprehensive and widespread guideline to conduct systematic reviews of outcome measurement instruments, but key information is often missing in published reviews. This hinders the appraisal of the quality of outcome measurement instruments, impacts the decisions of knowledge users regarding their appropriateness, and compromises reproducibility and interpretability of the reviews' findings. To facilitate sufficient, transparent, and consistent reporting of systematic reviews of outcome measurement instruments, an extension of the PRISMA (Preferred Reporting of Items for Systematic reviews and Meta-Analyses) 2020 guideline will be developed: the PRISMA-COSMIN guideline. METHODS The PRISMA-COSMIN guideline will be developed in accordance with recommendations for reporting guideline development from the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network. First, a candidate reporting item list will be created through an environmental literature scan and expert consultations. Second, an international Delphi study will be conducted with systematic review authors, biostatisticians, epidemiologists, psychometricians/clinimetricians, reporting guideline developers, journal editors as well as patients, caregivers, and members of the public. Delphi panelists will rate candidate items for inclusion on a 5-point scale, suggest additional candidate items, and give feedback on item wording and comprehensibility. Third, the draft PRISMA-COSMIN guideline and user manual will be iteratively piloted by applying it to systematic reviews in several disease areas to assess its relevance, comprehensiveness, and comprehensibility, along with usability and user satisfaction. Fourth, a consensus meeting will be held to finalize the PRISMA-COSMIN guideline through roundtable discussions and voting. Last, a user manual will be developed and the final PRISMA-COSMIN guideline will be disseminated through publications, conferences, newsletters, and relevant websites. Additionally, relevant journals and organizations will be invited to endorse and implement PRISMA-COSMIN. Throughout the project, evaluations will take place to identify barriers and facilitators of involving patient/public partners and employing a virtual process. DISCUSSION The PRISMA-COSMIN guideline will ensure that the reports of systematic reviews of outcome measurement instruments are complete and informative, enhancing their reproducibility, ease of use, and uptake.
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Affiliation(s)
- Ellen B M Elsman
- Epidemiology and Data Science, Amsterdam UMC location Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands. .,Quality of Care, Amsterdam Public Health, Amsterdam, The Netherlands.
| | - Nancy J Butcher
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lidwine B Mokkink
- Epidemiology and Data Science, Amsterdam UMC location Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands.,Methodology, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Caroline B Terwee
- Epidemiology and Data Science, Amsterdam UMC location Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands.,Methodology, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Andrea Tricco
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.,Epidemiology Division and Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Queen's Collaboration for Health Care Quality Joanna Briggs Institute Centre of Excellence, Queen's University, Kingston, Canada
| | - Joel J Gagnier
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, London, Ontario, Canada.,Department of Surgery, Schulich School of Medicine and Dentistry, London, Ontario, Canada.,Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Olalekan Lee Aiyegbusi
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Carolina Barnett
- Division of Neurology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | | | - David Moher
- Centre for Journalology, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.,Management and Evaluation, Institute of Health Policy, University of Toronto, Toronto, Ontario, Canada.,Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
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11
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Elsman EBM, Mokkink LB, Langendoen-Gort M, Rutters F, Beulens J, Elders PJM, Terwee CB. Systematic review on the measurement properties of diabetes-specific patient-reported outcome measures (PROMs) for measuring physical functioning in people with type 2 diabetes. BMJ Open Diabetes Res Care 2022; 10:e002729. [PMID: 35675952 PMCID: PMC9185403 DOI: 10.1136/bmjdrc-2021-002729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 05/09/2022] [Indexed: 11/03/2022] Open
Abstract
We aimed to systematically assess the measurement properties of diabetes-specific patient-reported outcome measures (PROMs) for measuring physical functioning, one of the core outcomes, in adults with type 2 diabetes.We performed a systematic literature search for PROMs or subscales measuring physical function that were validated to at least some extent in EMBASE and MEDLINE. Measurement properties were evaluated according to the COSMIN guideline for systematic reviews of PROMs.In total 21 articles were included, describing 12 versions of 7 unique diabetes-specific PROMs or subscales measuring physical functioning. In general, there were few high-quality studies on measurement properties of PROMs measuring physical functioning in adults with type 2 diabetes. The Dependence/Daily Life subscale of the Diabetic Foot Ulcer Scale-Short Form (DFS-SF) and the Impact of Weight on Activities of Daily Living Questionnaire (IWADL) were most extensively evaluated. Both had sufficient ratings for aspects of content validity, although with mostly very low-quality evidence. Sufficient ratings for structural validity, internal consistency, and reliability were also found for both instruments, but responsiveness was rated inconsistent for both instruments. The other PROMs or subscales often had insufficient aspects of content validity, or their unidimensionality could not be confirmed.This systematic review showed that the Dependence/Daily Life subscale of the DFS-SF and the IWADL could be used to measure physical functioning in people with type 2 diabetes in research or clinical practice, while keeping the limitations of these instruments in mind. The measurement properties that have not been evaluated extensively for these PROMs should be evaluated in future studies.The study protocol was registered in the PROSPERO database, number CRD42021234890.
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Affiliation(s)
- Ellen B M Elsman
- Department of Epidemiology and Data Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Lidwine B Mokkink
- Department of Epidemiology and Data Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Marlous Langendoen-Gort
- Department of General Practice and Elderly Care, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Femke Rutters
- Department of Epidemiology and Data Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Joline Beulens
- Department of Epidemiology and Data Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Petra J M Elders
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
- Department of General Practice and Elderly Care, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Caroline B Terwee
- Department of Epidemiology and Data Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
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12
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Elsman EBM, van Munster EPJ, van Nassau F, Verstraten P, van Nispen RMA, van der Aa HPA. Perspectives on Implementing the Patient Health Questionnaire-4 in Low-Vision Service Organizations to Screen for Depression and Anxiety. Transl Vis Sci Technol 2022; 11:16. [PMID: 35024786 PMCID: PMC8762693 DOI: 10.1167/tvst.11.1.16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose To describe the process of implementing a screening questionnaire for depression and anxiety, the Patient Health Questionnaire-4 (PHQ-4), in low-vision service (LVS) organizations. Methods This study consisted of three parts: (1) a usability study combined with semistructured interviews, in which clients (n = 10) of LVS organizations expressed their preference for using the PHQ-4; (2) a feasibility study, in which the PHQ-4 was implemented on a small scale and its use was evaluated, involving health care providers (n = 6) and clients (n = 9); and (3) semistructured interviews to identify barriers and facilitators for implementing the PHQ-4 according to health care providers (n = 6) and managers (n = 4) of LVS organizations. Results were integrated into themes and linked to constructs of the Consolidated Framework for Implementation Research (CFIR). Results Six themes were derived from the substudies: (1) quality of the intervention, (2) applicability for clients of LVS organizations, (3) attitude and needs of clients, (4) attitude of health care providers, (5) support within LVS organizations, and (6) embedment in current practice. Results could be linked to 12 CFIR constructs. The constructs "relative advantage," "patient needs and resources," and "available resources" emerged most prominently in our themes as either barrier or facilitator. Conclusions The PHQ-4 seems an appropriate screening instrument for use in LVS organizations because of its quality and adaptable use. It might provide opportunities to timely detect depression and anxiety, but challenges in implementing the PHQ-4 should be considered. Translational Relevance Barriers and facilitators for implementing the PHQ-4 may also apply to implementing other questionnaires in LVS organizations.
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Affiliation(s)
- Ellen B M Elsman
- Department of Ophthalmology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Edine P J van Munster
- Department of Ophthalmology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.,Expertise Innovation Knowledge, Robert Coppes Foundation, Vught, The Netherlands
| | - Femke van Nassau
- Department of Public and Occupational Health, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Peter Verstraten
- Expertise Innovation Knowledge, Robert Coppes Foundation, Vught, The Netherlands
| | - Ruth M A van Nispen
- Department of Ophthalmology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Hilde P A van der Aa
- Department of Ophthalmology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.,Expertise Innovation Knowledge, Robert Coppes Foundation, Vught, The Netherlands
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13
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Elsman EBM, Koel M, van Nispen RMA, van Rens GHMB. Quality of Life and Participation of Children With Visual Impairment: Comparison With Population Reference Scores. Invest Ophthalmol Vis Sci 2021; 62:14. [PMID: 34115092 PMCID: PMC8196425 DOI: 10.1167/iovs.62.7.14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Ellen B M Elsman
- Department of Ophthalmology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Amsterdam Public Health Research Institute, MB Amsterdam, The Netherlands
| | - Mitchel Koel
- Department of Ophthalmology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Amsterdam Public Health Research Institute, MB Amsterdam, The Netherlands
| | - Ruth M A van Nispen
- Department of Ophthalmology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Amsterdam Public Health Research Institute, MB Amsterdam, The Netherlands
| | - Ger H M B van Rens
- Department of Ophthalmology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Amsterdam Public Health Research Institute, MB Amsterdam, The Netherlands
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14
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Elsman EBM, van Nispen RMA, van Rens GHMB. 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. J Patient Rep Outcomes 2020; 4:62. [PMID: 32700170 PMCID: PMC7376774 DOI: 10.1186/s41687-020-00228-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 07/07/2020] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Ellen B M Elsman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Ophthalmology, Amsterdam Public Health Research Institute, location VUmc, PK4X 187, De Boelelaan 1117, PO Box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - Ruth M A van Nispen
- Amsterdam UMC, Vrije Universiteit Amsterdam, Ophthalmology, Amsterdam Public Health Research Institute, location VUmc, PK4X 187, De Boelelaan 1117, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Gerardus H M B van Rens
- Amsterdam UMC, Vrije Universiteit Amsterdam, Ophthalmology, Amsterdam Public Health Research Institute, location VUmc, PK4X 187, De Boelelaan 1117, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
- Elkerliek Hospital, Ophthalmology, Wesselmanlaan 25, 5707 HA, Helmond, The Netherlands
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15
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Elsman EBM, Peeters CFW, van Nispen RMA, van Rens GHMB. Network Analysis of the Participation and Activity Inventory for Children and Youth (PAI-CY) 7-12 Years with Visual Impairment. Transl Vis Sci Technol 2020; 9:19. [PMID: 32821516 PMCID: PMC7409088 DOI: 10.1167/tvst.9.6.19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/24/2020] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Ellen B M Elsman
- Department of Ophthalmology, Amsterdam UMC, Vrije Universiteit Amsterdam, The Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Carel F W Peeters
- Department of Epidemiology & Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, The Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Ruth M A van Nispen
- Department of Ophthalmology, Amsterdam UMC, Vrije Universiteit Amsterdam, The Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Ger H M B van Rens
- Department of Ophthalmology, Amsterdam UMC, Vrije Universiteit Amsterdam, The Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.,Department of Ophthalmology, Elkerliek Hospital, Helmond, The Netherlands
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16
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Schakel W, Bode C, Elsman EBM, van der Aa HPA, de Vries R, van Rens GHMB, van Nispen RMA. The association between visual impairment and fatigue: a systematic review and meta-analysis of observational studies. Ophthalmic Physiol Opt 2020; 39:399-413. [PMID: 31696537 PMCID: PMC6899802 DOI: 10.1111/opo.12647] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 09/21/2019] [Indexed: 01/30/2023]
Abstract
PURPOSE The aim was to compare fatigue levels between patients with visual impairment and controls with normal sight and to examine the association between fatigue and vision loss severity. METHODS A systematic literature search was performed using databases of PubMed, Embase, PsycINFO and Cochrane to identify observational studies with outcomes related to fatigue (e.g. vitality subscale of the Short-Form 36, Fatigue Assessment Scale). A meta-analysis was performed using standardised mean differences (SMDs) and odds ratios (OR) to quantitatively summarise the association between visual impairment and fatigue. Sources of heterogeneity were explored by subgroup and sensitivity analyses. Study quality was assessed with the Newcastle-Ottawa scale. RESULTS After reviewing 4477 studies, 22 studies with a total of 40 004 participants were included, of which 18 contributed to meta-analysis. Among these, eight were assessed as moderate quality studies and 10 as high quality studies. Pooled analysis involving 2500 patients and 8395 controls showed higher fatigue severity levels (S.M.D. = -0.36, 95% CI -0.50 to -0.22, 14 studies) among visually impaired patients compared to normally sighted controls. This effect size was small and persisted in sensitivity analyses that involved study quality, fatigue assessment tools and visual acuity data. Furthermore, pooled analysis of four studies including 2615 patients and 5438 controls showed a significant association between visual impairment and fatigue (OR = 2.61, 95% CI 1.69 to 4.04). Secondary meta-analysis of four studies showed no significant difference in fatigue severity (S.M.D. = 0.01, 95% CI -0.37 to 0.39) between patients with moderate visual impairment and patients with severe visual impairment or blindness. CONCLUSIONS Current moderate to high quality evidence suggest that patients with visual impairment experience more severe fatigue symptoms than persons with normal sight. However, a limited number of available studies indicates that fatigue is not associated with severity of vision loss. Future studies are required to determine which factors and underlying mechanisms may explain the association between visual impairment and fatigue. Discussing fatigue at an early stage and developing intervention options for vision-related fatigue should be considered within the field of low vision rehabilitation.
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Affiliation(s)
- Wouter Schakel
- Department of Ophthalmology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands.,Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Christina Bode
- Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - Ellen B M Elsman
- Department of Ophthalmology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands.,Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Hilde P A van der Aa
- Department of Ophthalmology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands.,Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Ralph de Vries
- Medical Library, Vrije Universiteit, Amsterdam, The Netherlands
| | - Gerardus H M B van Rens
- Department of Ophthalmology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands.,Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.,Department of Ophthalmology, Elkerliek Hospital, Helmond, The Netherlands
| | - Ruth M A van Nispen
- Department of Ophthalmology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands.,Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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17
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Elsman EBM, Tadić V, Peeters CFW, van Rens GHMB, Rahi JS, van Nispen RMA. Cross-cultural validation of the Functional Vision Questionnaire for Children and Young People (FVQ_CYP) with visual impairment in the Dutch population: challenges and opportunities. BMC Med Res Methodol 2019; 19:221. [PMID: 31795950 PMCID: PMC6889469 DOI: 10.1186/s12874-019-0875-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 11/21/2019] [Indexed: 11/10/2022] Open
Abstract
Background To assess cross-cultural validity between Dutch and English versions of the FVQ_CYP, a patient-reported outcome measure developed in the United Kingdom (UK) for children and adolescents with (severe) visual impairment or blindness (VI for brevity) to measure functional vision. Methods The 36-item FVQ_CYP was translated and adapted into Dutch using standard guidelines. The questionnaire was administered to Dutch children and adolescents aged 7–17 years (N = 253) with impaired vision (no restrictions regarding acuity). Data were compared to existing UK data of children and adolescents aged 10–15 years (N = 91) with VI (acuity LogMar worse than 0.48). As with the original UK FVQ_CYP validation, a rating scale model (RSM) was applied to the Dutch data. Results Minor adaptations were needed in translation-rounds. Significant differences in item responses were found between the Dutch and UK data. Item response theory assumptions were met, but fit to the RSM was unsatisfactory. Therefore, psychometric properties of the Dutch FVQ_CYP were analysed irrespective of the original model and criteria used. A graded response model led to the removal of 12 items due to missing data, low information, overlapping content and limited relevance to Dutch children. Fit indices for the remaining 24 items were adequate. Conclusions Differences in population characteristics, distribution of responses, non-invariance at the model level and small sample sizes challenged the cross-cultural validation process. However, the Dutch adapted FVQ_CYP showed high measurement precision and broad coverage of items measuring children’s functional vision. The underlying reasons for differences between countries in instrument performance are discussed with implications for future studies.
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Affiliation(s)
- Ellen B M Elsman
- Department of Ophthalmology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Amsterdam Public Health research institute, Amsterdam, the Netherlands.
| | - Valerija Tadić
- School of Human Sciences, University of Greenwich, London, UK.,Life Course Epidemiology and Biostatistics Section, Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Carel F W Peeters
- Department of Epidemiology & Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, the Amsterdam Public Health research institute, Amsterdam, the Netherlands
| | - Ger H M B van Rens
- Department of Ophthalmology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Amsterdam Public Health research institute, Amsterdam, the Netherlands.,Department of Ophthalmology, Elkerliek Hospital, Helmond, the Netherlands
| | - Jugnoo S Rahi
- Life Course Epidemiology and Biostatistics Section, Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Ulverscroft Vision Research Group, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Ruth M A van Nispen
- Department of Ophthalmology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Amsterdam Public Health research institute, Amsterdam, the Netherlands
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18
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Elsman EBM, van Nispen RMA, van Rens GHMB. Psychometric evaluation of the Participation and Activity Inventory for Children and Youth (PAI-CY) 0-2 years with visual impairment. Qual Life Res 2019; 29:775-781. [PMID: 31673921 PMCID: PMC7028793 DOI: 10.1007/s11136-019-02343-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2019] [Indexed: 12/01/2022]
Abstract
Purpose To identify and monitor the developmental and participation needs of visually impaired (VI) children, the Participation and Activity Inventory for Children and Youth (PAI-CY) has recently been developed involving end-users as stakeholders. The aim was to investigate psychometric properties of the PAI-CY for children between 0 and 2 years. Methods Responses from 115 parents were included in item analyses, after which a combination of classical test theory and item response theory (IRT) was used. Internal consistency, known-group validity, and test–retest reliability at item and scale level were investigated. Results After deleting four items, the PAI-CY met IRT assumptions, i.e., unidimensionality, local independence, and monotonicity, and satisfactory model fit was obtained. Participants with more severe VI and comorbidity scored significantly worse than those with less severe VI and without comorbidity, supporting known-group validity. Satisfactory internal consistency and test–retest reliability were obtained (Cronbach’s alpha 0.95, kappa 0.60–0.91, ICC 0.920). Conclusions The PAI-CY 0–2 years has acceptable psychometric properties and can be used to systematically assess and monitor developmental and participation needs of very young children with VI from parents’ perspectives in low vision practice and research. Confirmation of psychometric properties is necessary, possibly facilitating further item reduction, increased precision, and improved user-friendliness.
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Affiliation(s)
- Ellen B M Elsman
- Department of Ophthalmology, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands. .,Amsterdam UMC, VU University Medical Center, PK4X191, PO Box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - Ruth M A van Nispen
- Department of Ophthalmology, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Gerardus H M B van Rens
- Department of Ophthalmology, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands.,Department of Ophthalmology, Elkerliek Hospital, Wesselmanlaan 25, 5707 HA, Helmond, The Netherlands
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Elsman EBM, van Nispen RMA, van Rens GHMB. Psychometric evaluation of a new proxy-instrument to assess participation in children aged 3-6 years with visual impairment: PAI-CY 3-6. Ophthalmic Physiol Opt 2019; 39:378-391. [PMID: 31468574 PMCID: PMC6851879 DOI: 10.1111/opo.12642] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/08/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Ellen B M Elsman
- Department of Ophthalmology, Amsterdam Public Health research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ruth M A van Nispen
- Department of Ophthalmology, Amsterdam Public Health research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Gerardus H M B van Rens
- Department of Ophthalmology, Amsterdam Public Health research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Ophthalmology, Elkerliek Hospital, Helmond, The Netherlands
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Elsman EBM, Al Baaj M, van Rens GHMB, Sijbrandi W, van den Broek EGC, van der Aa HPA, Schakel W, Heymans MW, de Vries R, Vervloed MPJ, Steenbergen B, van Nispen RMA. Interventions to improve functioning, participation, and quality of life in children with visual impairment: a systematic review. Surv Ophthalmol 2019; 64:512-557. [PMID: 30703405 DOI: 10.1016/j.survophthal.2019.01.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 01/10/2019] [Accepted: 01/17/2019] [Indexed: 11/19/2022]
Abstract
Visual impairment in childhood often has life-long implications. To aim for the highest levels of functioning, participation, and quality of life and to ensure children's well-being, children should be entitled to the most effective rehabilitation programs. We review evidence for the effectiveness of rehabilitation interventions for children with visual impairment to improve skills and behavior, thereby improving participation and quality of life as an ultimate goal. Of the 441 potentially relevant articles identified, 66 studies met our inclusion criteria (i.e., 28 randomized controlled trials, 18 nonrandomized controlled trials, and 20 before-after comparisons). The results suggest that sports camps, prescription and training in the use of low vision devices, and oral hygiene programs might be effective in improving functioning and elements of participation and quality of life in children with visual impairment. Other interventions showed mixed or negative results. The results should be interpreted with caution because of moderate to high risk of bias and suboptimal reporting. Heterogeneity of results and the use of over 50 different outcome measures prevented a meta-analysis. Future studies should focus on promising interventions for which effectiveness is still unclear (e.g., mobility, social skills), with adequately designed methodology.
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Affiliation(s)
- Ellen B M Elsman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Ophthalmology, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Mo Al Baaj
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Ophthalmology, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Gerardus H M B van Rens
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Ophthalmology, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands; Department of Ophthalmology, Elkerliek Hospital, Helmond, The Netherlands
| | | | | | - Hilde P A van der Aa
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Ophthalmology, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Wouter Schakel
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Ophthalmology, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Martijn W Heymans
- Amerdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Ralph de Vries
- Medical Library, Vrije Universiteit, Amsterdam, The Netherlands
| | | | - Bert Steenbergen
- Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
| | - Ruth M A van Nispen
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Ophthalmology, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Elsman EBM, Leerlooijer JN, Ter Beek J, Duijzer G, Jansen SC, Hiddink GJ, Feskens EJM, Haveman-Nies A. Using the intervention mapping protocol to develop a maintenance programme for the SLIMMER diabetes prevention intervention. BMC Public Health 2014; 14:1108. [PMID: 25346512 PMCID: PMC4286928 DOI: 10.1186/1471-2458-14-1108] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 10/21/2014] [Indexed: 11/30/2022] Open
Abstract
Background Although lifestyle interventions have shown to be effective in reducing the risk for type 2 diabetes mellitus, maintenance of achieved results is difficult, as participants often experience relapse after the intervention has ended. This paper describes the systematic development of a maintenance programme for the extensive SLIMMER intervention, an existing diabetes prevention intervention for high-risk individuals, implemented in a real-life setting in the Netherlands. Methods The maintenance programme was developed using the Intervention Mapping protocol. Programme development was informed by a literature study supplemented by various focus group discussions and feedback from implementers of the extensive SLIMMER intervention. Results The maintenance programme was designed to sustain a healthy diet and physical activity pattern by targeting knowledge, attitudes, subjective norms and perceived behavioural control of the SLIMMER participants. Practical applications were clustered into nine programme components, including sports clinics at local sports clubs, a concluding meeting with the physiotherapist and dietician, and a return session with the physiotherapist, dietician and physical activity group. Manuals were developed for the implementers and included a detailed time table and step-by-step instructions on how to implement the maintenance programme. Conclusions The Intervention Mapping protocol provided a useful framework to systematically plan a maintenance programme for the extensive SLIMMER intervention. The study showed that planning a maintenance programme can build on existing implementation structures of the extensive programme. Future research is needed to determine to what extent the maintenance programme contributes to sustained effects in participants of lifestyle interventions. Electronic supplementary material The online version of this article (doi:10.1186/1471-2458-14-1108) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ellen B M Elsman
- Division of Human Nutrition; Academic Collaborative Centre AGORA, Wageningen University, P,O, Box 8129, 6700, VE, Wageningen, The Netherlands.
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