DOMENE WHO - QoL
DOMENE WHO - QoL
DOMENE WHO - QoL
Copyright© 2004
CHAPTER TWENTY
1
2 ECOSSE, et al.
lows that measurement of health and health care effects must include not
only an indication of frequency and severity of diseases but also changes
in well-being that are assessed by measuring Quality of Life (QOL).
WHO defines QOL as individuals’ perception of their position in life
relative to their cultural context including personal goals, expectations,
standards, and concerns. It is a broad concept, affected in a complex way,
first, by physical health, psychological state, level of independence, so-
cial relationships, and personal beliefs, and, secondly, by the relationship
of these factors to salient environmental features.
With the aid of 15 collaborating centers around the world, WHO has
developed two profiles for measuring QOL: WHOQOL-100 and
WHOQOL-BREF (see The WHOQOL Group, 1994a, 1994b, and 1998),
which can be used in a variety of cultural settings to compare populations
and countries. These instruments are currently used widely in medical
practice, research, auditing, and policy-making. Further WHOQOL de-
velopment in other languages is progressing with WHOQOL-100 now
available in over 20 different language versions. The WHOQOL-BREF is
an abbreviated 26-item version of WHOQOL-100 based on data from the
field trial version of WHOQOL-100.
The objective of the current project is to explore development of a
short list of items that indexes QOL with a single score. This survey
would reflect a construct that is:
· comparable to original content structure of WHOQOL-100 and
WHOQOL-BREF
· psychometrically reliable
· reasonably comparable cross-culturally.
There is great need for a short standardized questionnaire for interna-
tional comparative population surveys and economic studies. Indeed, there
is substantial demand from several international organizations such as
WHO for a reliable, short instrument measuring QOL in health service
research and health economics. If it were possible to develop such a tool,
it could complement data currently collected by generic international pro-
files such as WHOQOL-100 and -BREF.
After thoroughly evaluating alternative measurement approaches such
as classical test theory and item response theory, we selected the Rasch
model (Wright and Stone, 1979; Wright and Masters, 1982; Andrich, 1978,
1982) to identify a 10 to 15 item questionnaire capable of measuring the
QUALITY OF LIFE IN SIX DATA SETS 3
1/ Physical health 3 facets Energy and fatigue Pain and discomfort Sleep and rest
12 items
ECOSSE, et al.
2/ Psychological 5 facets Body image and appearance Negative feelings Positive feelings
20 items
Work capacity
5/ Environment 8 facets Financial resources Freedom, physical safety Health and social care:
32 items and security accessibility and quality
Table 3
Age distribution
Argentina France GB Hong-Kong Spain USA Total
Number 421 298 330 828 298 441 2,601
Mean age 47.1 44 48 45.2 42.6 44.2 45.3
SD 14.6 15.4 15.7 16.1 14 15.7 15.5
Minimum 20 17 9 12 19 20 9
Maximum 80 81 85 92 80 90 92
Note: Abbreviations: (GB = Great Britain), (SD = standard deviation).
Table 4
Health status
Argentina France GB Hong-Kong Spain USA* Total
N % N % N % N % N % N % N %
Healthy 240 57 47 15.9 114 32.3 155 18.3 194 63.8 — — 750 33.8
Ill 181 43 249 84.1 239 67.1 690 81.5 110 36.2 — — 1469 66.1
MD 0 0 0 0 0 0 2 0.2 0 0.0 — — 2 0.1
Total 421 100 296 100 353 100 847 100 304 100.0 — — 2221 100
Note: The WHOQOL contains response scales concerned with intensity (Extremely -
…- Not at all), capacity (Completely -…- Not at all), frequency (Always -…-Never) or
evaluation (Very dissatisfied -…- Very satisfied ; Very poor -…- Very good).
Abbreviations: (GB = Great Britain), (SD = standard deviation), (MD = missing data).
* USA health status was not available.
QUALITY OF LIFE IN SIX DATA SETS 7
100
90
80
70
60
50
40
30
20
10
0
-2.5 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5
Abili ty
model. (Their fit values were higher than 3.5 or lower than -3.5 calcu-
lated using RUMM). The mean fit values and percentages of misfitting
persons are presented by country in Table 6. Thirty-three percent of Hong
Kong persons were removed from the analysis, 27 percent of Argentinean,
20 percent of French, 21 percent of British, 35 percent of Spanish, and 18
percent of American data. Using the targeted data base, a fit index and a
measure were calculated for each person. The results in Tables 7 and 8
show QOL measures for persons fitting the model are significantly higher
than for misfitting persons. A significant difference in terms of culture,
gender and age also appears between persons who fit and those who did
Table 5
Summary of missing data generated
Missing data Missing data
before targeting (%) after targeting (%)
France 1.26 6.19
Spain 2.77 4.30
Argentina 0.02 1.99
Hong Kong 0.99 6.49
USA 1.29 9.91
GB 4.62 8.64
Total 1.6 6.35
10 ECOSSE, et al.
Table 6
Distribution of person fit values and percentage by country
N & (%)
Country N Mean* Std Dev Minimum Maximum Do not fit
Argentina 421 -1.3 3.0 -12.9 6.9 113 (27)
Spain 301 -0.4 4.1 -13.9 8.7 106 (35)
France 293 0.5 2.7 -6.8 9.0 60 (20)
UK 340 -0.7 2.8 -9.9 6.1 72 (21)
Hong-Kong 841 -0.5 3.7 -23.0 10.8 280 (33)
USA 441 0.0 2.7 -13.4 6.8 78 (18)
Total 2637 -0.5 3.3 -23.0 10.8 709 (27)
*P < .001
Table 7
Relation of person fit to gender and health status
Fit Did not fit
Gender*
Men 878 (71%) 355 (29%)
Women 1036 (75%) 349 (25%)
Health status**
Healthy 544 (73%) 204 (27%)
Unhealthy 1019 (70%) 427 (30%)
Total 1563 (71%) 631 (29%)
Note: Health status is missing for the American data base
*P < .05
**NS
Table 8
Percentage of persons fit by age and QOL measure
Fit Did not fit
Age*
Mean 44.7 46.6
SD 15.5 15.6
QOL status*
Mean 0.51 0.32
SD 0.71 0.64
*P < .001
QUALITY OF LIFE IN SIX DATA SETS 11
Item Selection
Elimination of misfitting items. Only 39 items of the initial 100 were
eliminated because their chi-square values were higher than 38. They were:
G1, G2, G3, G4, F1.1, F1.3, F2.1, F2.3, F4.2, F4.4, F6.3, F6.4, F7.2, F7.3,
F8.1, F10.1, F10.3, F11.1, F11.2, F11.3, F11.4, F12.2, F12.3, F12.4, F13.3,
F15.2, F15.4, F16.3, F16.4, F18.4, F19.1, F19.2, F19.4, F21.4, F22.2, F22.4,
F24.1, F24.3, F24.4. Facet 1 (Overall QOL) and facet 11 (Medication) were
completely eliminated (see Appendix for item labels.
Differential item function by language version. By plotting paired
calibrations with associated confidence intervals, some variation in item
calibration was found across cultures. Figure 3 shows location param-
eters for 61 initial item pairs between USA and Argentina. Figure 4 shows
this relationship between UK and USA. Table 9 presents the 25 items
with greatest equivalence across six countries. The last column shows
that item F204 is the most homogenous with 14 out of 15 tests proving
positive. Out of 100 initial items, none were found to be completely equiva-
lent across six countries. (None of the items were positive 15 times out of
15.) Figure 5 and Table 10 provide additional information about retained
items.
Excluding Argentina which showed the greatest homogeneity, the test
on average was positive 6.9 times out of 10. The reduced set of 25 items
shows a relatively restricted range between –1 and 1 logits. With the
exception of items F232, F234, F91, and F131, however, the category
1.4
1.2
Argentina calibration (Logits)
1.0
0.8
0.6
0.4
0.2
0.0
-0.2
-0.4
-0.6
-0.8
-1.0
-1.2
-1.0 -0.8 -0.6 -0.4 -0.2 0.0 0.2 0.4 0.6 0.8 1.0
Figure 3. Plot of item difficulties between USA and Argentina with 99 percent
control lines
12 ECOSSE, et al.
thresholds covered the full range of QOL measures. (All domains and
facets with exception of medication were preserved.) Consequently, these
items provide a broad range of quality of life coverage on the continuum.
Discussion
In preliminary data analyses from four countries (Leplège, 2000), we
discarded items with unordered thresholds. This time, however, we ana-
lyzed six data bases without discarding items with unordered thresholds.
This has, at least, the advantage of adding 12 items to the item pool con-
sidered for cross-cultural comparison. In regards to the item selection
criterion, we chose to remove items if fit values were not between –3.5 to
3.5 because a large number of misfitting items increase the probability
that persons will not fit. In regards to differential item functioning, statis-
tical control lines (99 percent confidence interval) were drawn around the
identity line to guide interpretation and any items falling outside these
control lines were considered as non-equivalent. A more classical crite-
rion would have been to use a 95 percent confidence interval, but we
opted for 99 percent. Given both complexity of the notion of cultural
equivalence and qualitative work that has been devoted to ensuring cul-
tural equivalence, we found it reasonable to adopt stricter criteria. It is
also important to note that the ends of the confidence interval usually
flare because standard errors are typically larger for easier or harder items.
In these data, QOL items are concentrated in the center where standard
errors are narrow which tends to diminish this appearance.
1.2
1.0
0.8
UK calibration (Logits)
0.6
0.4
0.2
0.0
-0.2
-0.4
-0.6
-0.8
-1.0
-1.2
-1.0 -0.8 -0.6 -0.4 -0.2 0.0 0.2 0.4 0.6 0.8 1.0
Figure 4. Plot of item difficulties between USA and UK with 99 percent control
lines
QUALITY OF LIFE IN SIX DATA SETS 13
13 F121
12 F204
11 F201
10
F14
9 F92
8
F84
7
F233
6
F144
5
F173
4
F131
3
2 F91
1 F234
0 F232
-2.50 -2.00 -1.50 -1.00 -0.50 0.00 0.50 1.00 1.50 2.00 2.50 3.00
Logit
Table 10
Difficulty and threshold estimates of 25 retained items.
Thresholds
Item Difficulty 1 2 3 4 Label
F181 0.54 -0.55 -0.16 1.13 1.72 Have you enough money to meet your
needs?
F153 0.52 -0.39 -0.6 0.84 2.21 How satisfied are you with your sex
life?
F151 0.48 -0.29 -0.74 0.93 2.02 How would you rate your sex life?
F223 0.29 -1.79 -0.4 0.57 2.78 How satisfied are you with your
physical environment
F33 0.24 -1.37 0.18 0.17 2 How satisfied are you with your sleep?
F221 0.24 -0.71 -1.14 0.84 1.98 How healthy is your physical
environment?
F142 0.21 -0.78 -0.31 0.31 1.62 To what extent can you count on your
friends when you need them?
F203 0.2 -1.97 -0.67 0.66 2.78 How satisfied are you with your
opportunities for acquiring new skills?
F141 0.18 -1.22 -0.4 0.38 1.97 Do you get the kind of support from
others that you need?
F242 0.04 -0.83 -0.79 0.15 1.64 To what extent do you feel your life to
be meaningful?
F54 0.02 -2.03 -0.29 0.05 2.35 How satisfied are you with your ability
to make decisions?
F172 0 -0.92 -0.93 0.29 1.57 To what degree does the quality of
your home meet your needs?
F121 -0.03 -0.86 -0.52 0.25 1.01 Are you able to work?
F204 -0.04 -2.14 -0.96 0.23 2.73 How satisfied are you with your
opportunities to learn new information
F201 -0.09 -1.7 -0.84 0.4 1.77 How available to you is the information
that you need in your day-to-day life?
F14 -0.09 -1.19 0.05 0.2 0.57 To what extent do you feel that
(physical) pain prevents you from
doing what you need to do?
F92 -0.15 -1.21 -0.26 0.04 0.86 How satisfied are you with your ability
to move around?
F84 -0.16 -1.6 0.25 -0.17 0.89 How much do any feelings of
depression bother you?
F233 -0.16 -1.88 -0.91 0.1 2.04 How satisfied are you with your
transport?
F144 -0.17 -1.69 -0.95 -0.05 2.03 How satisfied are you with the support
you get from your friends
F173 -0.27 -1.9 -0.63 -0.38 1.82 How satisfied are you with the
conditions of your living place?
F131 -0.33 -1.24 0.02 -0.28 0.19 How alone do you feel in your life?
F91 -0.39 -1.34 -0.95 0.29 0.45 How well are you able to get around?
F234 -0.54 -1.32 -0.43 -0.11 -0.3 How much do difficulties with transport
restrict your life?
F232 -0.55 -1.12 -0.61 -0.14 -0.34 To what extent do you have problems
with transport?
16 ECOSSE, et al.
Appendix
WHOQOL–100 questions
OVERALL QUALITY OF LIFE AND HEALTH
G1 How would you rate your quality of life?
G2 How satisfied are you with the quality of your life?
G3 In general, how satisfied are you with your life?
G4 How satisfied are you with your health?
DOMAIN I—PHYSICAL DOMAIN
1. Pain and discomfort
F1.1 How often do you suffer (physical) pain?
F1.2 Do you worry about your pain or discomfort?
F1.3 How difficult is it for you to handle any pain or discomfort?
F1.4 To what extent do you feel that (physical) pain prevents you from doing
what you need to do?
2. Energy and fatigue
F2.1 Do you have enough energy for everyday life?
F2.2 How easily do you get tired?
F2.3 How satisfied are you with the energy that you have?
F2.4 How much are you bothered by fatigue?
3. Sleep and rest
F3.1 How well do you sleep?
F3.2 Do you have any difficulties with sleeping?
F3.3 How satisfied are you with your sleep?
F3.4 How much do any sleep problems worry you?
DOMAIN II—PSYCHOLOGICAL DOMAIN
4. Positive feelings
F4.1 How much do you enjoy life?
F4.2 Do you generally feel content?
F4.3 How positive do you feel about the future?
F4.4 How much do you experience positive feelings in your life?
5. Thinking, learning, memory, and concentration
F5.1 How would you rate your memory?
F5.2 How satisfied are you with your ability to learn new information?
F5.3 How well are you able to concentrate?
F5.4 How satisfied are you with your ability to make decisions?
6. Self-esteem
F6.1 How much do you value yourself?
F6.2 How much confidence do you have in yourself?
F6.3 How satisfied are you with yourself?
F6.4 How satisfied are you with your abilities?
7. Body image and appearance
F7.1 Are you able to accept your bodily appearance?
F7.2 Do you feel inhibited by your looks?
F7.3 Is there any part of your appearance, which makes you feel uncomfortable?
F7.4 How satisfied are you with the way your body looks?
8. Negative feelings
F8.1 How often do you have negative feelings, such as blue mood, despair,
anxiety, and depression?
F8.2 How worried do you feel?
F8.3 How much do any feelings of sadness or depression interfere with your
everyday functioning?
F8.4 How much do any feelings of depression bother you?
DOMAIN III—LEVEL OF INDEPENDENCE
9. Mobility
F9.1 How well are you able to get around?
F9.2 How satisfied are you with your ability to move around?
F9.3 How much do any difficulties in mobility bother you?
F9.4 To what extent do any difficulties in movement affect your way of life?
10. Activities of daily living
F10.1 To what extent are you able to carry out your daily activities?
F10.2 To what extent do you have difficulty in performing your routine activities?
F10.3 How satisfied are you with your ability to perform your daily living
activities?
F10.4 How much are you bothered by any limitations in performing everyday
living activities?
11. Dependence on medication or treatments
F11.1 How dependent are you on medications?
F11.2 How much do you need any medication to function in your daily life?
F11.3 How much do you need any medical treatment to function in your daily
life?
F11.4 To what extent does your quality of life depend on the use of medical
substances or medical aids?
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