Rapid translation of quality of life measures for international clinical trials: avoiding errors in the minimalist approach

Translation and psychometric evaluation of a Chinese version of the SF-36 Health Survey in the United States

Outcome measures are rapidly becoming standard tools in the assessment of clinical effectiveness and in the measurement of health status in populations. In this article we document the development of a self-administered Chinese version of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and report the results of psychometric testing among 156 adult Chinese Americans in Boston, Massachusetts. Following the standard guidelines, a Chinese version of the SF-36 was developed through forward-backward translation techniques and committee review. We used psychometric methods to test assumptions underlying construction and scoring of scales and to evaluate the reliability and validity of the Chinese SF-36 as a measure of health status. The preliminary results indicated that missing value rates for the 36 items were consistently low. Item-discriminant validity was high (over 90% scaling successes) for six of the eight scales (Physical Functioning, Role-Physical, Bodily Pain, General Health, Role-Emotional, and Mental Health). Cronbach's alpha coefficient was above 0.70 criterion for all scales except Social Functioning. Reliability estimates also appeared to vary by sample characteristics. We discuss the implications of these findings and identify where further work will be required.

Perceptions of quality of life in Hispanic patients with cancer

PURPOSE

The purpose of this study was to describe perceptions of quality of life (QOL) of Hispanic patients with cancer pain.

DESCRIPTION OF STUDY

This qualitative pilot study is guided by the conceptual framework of pain and QOL. From interviews with 17 Hispanic patients with cancer pain, data on perceptions of QOL were analyzed and are reported here.

RESULTS

The study demonstrated the influence of culture on perceptions of QOL and the impact of pain on QOL. Several themes were identified for each domain of QOL, including physical, psychological, social, and spiritual well-being. The role of the family and faith in God were important components of QOL for all patients.

CLINICAL IMPLICATIONS

It is important for clinicians to devote greater attention to cultural assessment and to include cultural beliefs in cancer care to improve QOL for Hispanic patients. The role of the family and religious beliefs should be included in the planning and evaluation of each patient's care.

Influence of culture on cancer pain management in Hispanic patients

PURPOSE

The purpose of this pilot study was to describe the influence of culture on cancer pain management in Hispanic (Mexican and Central American) patients.

DESCRIPTION OF STUDY

This qualitative study is guided by the conceptual framework of the Pain and Quality of Life model and the Biocultural Model of Pain. It was developed as a companion study to a National Cancer Institute (NCI)-funded project to disseminate a pain education program for adult patients with cancer and their family care givers in community home-care agencies. After completing the NCI study, Hispanic subjects were invited to participate in the qualitative companion study. A total of 17 subjects, the majority of whom were women, were interviewed. The Hispanic Pain Experience Questionnaire (HPEQ) was used to elicit answers to open-ended questions regarding the perception and management of cancer pain.

RESULTS

Themes that emerged from the questionnaire were Influence of Culture, Expressions of Pain, Managing Pain/Medications, and Use of Nondrug Interventions. Responses suggest that culture, family beliefs, and religion contribute significantly to management and expression of pain by the patient and care giver. In addition, this group showed that pain may be approached with stoicism; therefore, lack of verbal or behavioral expression of pain does not indicate a lack of pain itself. These patients also demonstrated a reliance on folk beliefs and nondrug interventions. The most common reason cited for noncompliance with pharmacologic treatment was an inability to understand instructions.

CLINICAL IMPLICATIONS

When providing care to Hispanic patients, it is imperative to be nonjudgmental, sensitive, and respectful. To improve compliance, the multidisciplinary cancer team should 1) incorporate the patients' folk healthcare practices and beliefs into the plan of care when possible; 2) involve family members and friends in the patient's care, identifying one key family contact; and 3) ensure that instructions for medications are available in Spanish and understood by the patient and care giver. When patients' overall beliefs and values are respected, compliance with pharmacological and other interventions may increase accordingly.

Impact of epilepsy on QOL in a Portuguese population: exploratory study

OBJECTIVES

To develop an outcome measure of QOL (quality of life) for the Portuguese population; describe QOL in epileptics; analyse how QOL is affected by epilepsy and analyse how QOL is affected by patients' characteristics.

PATIENTS AND METHODS

Study of a consecutive sample of 92 epileptics from an outpatient clinic, men and women, aged 15-65, having the basic education level. Firm diagnosis of epilepsy (with or without seizures) without other illness. A questionnaire based on ESI-55 and Health Insurance Experiment Short-Forms was used. Principal component analysis (orthogonal varimax) showed a solution explaining 55.6 of total variance. After the inspection, the 33 items were grouped into 5 sub-scales (dimensions).

RESULTS

Results showed that QOL was poor for people with partial seizures. The best scores were found on patients now free from seizures.

CONCLUSION

The QOL measure is sensitive to cultural differences, demographic and disease variables which could explain the results found.

Construct validation of the USA-Spanish version of the SF-36 health survey in a Cuban-American population with benign prostatic hyperplasia

This study examined the USA-Spanish version of the SF-36 health survey (validated in Mexican-Americans) and tested its construct validity in Cuban-Americans with benign prostatic hyperplasia (BPH). The study evaluated the SF-36 and American Urological Association (AUA) Symptom Index scores of 264 individuals with BPH. Individuals were assigned to one of the following groups: non-Hispanics who received the English version, Cubans who received the English version and Cubans who received the Spanish version. The objective was to determine the correlation between the individuals' SF-36 and AUA Symptom Index scores. It was expected that patients in the severe category would have the lowest quality of life (QoL) scores. The analysis was conducted using a MANOVA with a planned comparisons procedure. For all eight scales, the English and Spanish versions of the SF-36 were able to classify individuals with mild/moderate symptoms of BPH as having statistically higher QoL scores than those with severe symptoms of BPH. We concluded that the USA-Spanish version of the SF-36 can differentiate between levels of symptom severity in individuals with BPH. More importantly the construct validity of the English and Spanish versions of the SF-36 was demonstrated through significant correlation with the theorized constructs.

'Equivalence' and the translation and adaptation of health-related quality of life questionnaires

The increasing use of health-related quality of life (HRQOL) questionnaires in multinational studies has resulted in the translation of many existing measures. Guidelines for translation have been published, and there has been some discussion of how to achieve and assess equivalence between source and target questionnaires. Our reading in this area had led us, however, to the conclusion that different types of equivalence were not clearly defined, and that a theoretical framework for equivalence was lacking. To confirm this we reviewed definitions of equivalence in the HRQOL literature on the use of generic questionnaires in multicultural settings. The literature review revealed: definitions of 19 different types of equivalence; vague or conflicting definitions, particularly in the case of conceptual equivalence; and the use of many redundant terms. We discuss these findings in the light of a framework adapted from cross-cultural psychology for describing three different orientations to cross-cultural research: absolutism, universalism and relativism. We suggest that the HRQOL field has generally adopted an absolutist approach and that this may account for some of the confusion in this area. We conclude by suggesting that there is an urgent need for a standardized terminology within the HRQOL field, by offering a standard definition of conceptual equivalence, and by suggesting that the adoption of a universalist orientation would require substantial changes to guidelines and more empirical work on the conceptualization of HRQOL in different cultures.

Evaluation of quality of life for diverse patient populations

Quality of life is used increasingly as a primary and secondary endpoint of clinical investigations of new therapies. Quality of life information may be especially useful for the assessment of cancer treatments, where increases in survival may be accompanied by detrimental side effects. The recognition of the importance of quality of life has led to the recent proliferation of cancer specific quality of life instruments. As more is understood about the heterogeneity of patient populations, however, we must assess how culturally defined factors may impact patient quality of life and its assessment. Quality of life instruments are diverse, ranging from those focusing on objective measures of functionality to those assessing subjective measures of patient preferences for their current health state. These instruments have been developed for use in the general population and for disease-specific populations. Assessment of the appropriateness of potential quality of life instruments in specific clinical settings, in addition to understanding the cultural diversity of the clinical population being studied, will guide the researcher in the choice of an appropriate quality of life instrument for cancer clinical trials.