Validation of the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-31) in Chinese

Modelling the factors associated with quality of life in women with osteoporosis: A cross-sectional study

Background

Considering the important factors contributing to different health-related quality of life (HRQoL) subscales is essential for implementing preventive measures to increase the HRQoL among women with osteoporosis. We here evaluated the variables related to the mental and physical HRQoL in a sample of Iranian osteoporotic women.

Methods

In this cross-sectional study, the participants included 111 women with osteoporosis in 2013. Physical and mental of HRQoL were measured by the ECOS-16 questionnaire. Other variables included BMD t-score (Osteoporosis was diagnosed based on bone mineral density (BMD) with BMD t-score < -2.5), age, body mass index, educational level, marital status, duration of the disease, history of bone fracture in the past year, the number of pregnancies, and weekly walking hours. Final regression coefficients were obtained based on the total effects of estimations (decompositions of effects into direct, indirect and total effects) by structural equation model (SEM) analysis.

Results

The mean scores of physical and mental domains of HRQoL were 54(21) and 54(25), respectively. The mean of BMD t-score was -3.2 (0.9). Based on the regression coefficients obtained in the SEM model, weekly walking hours(2.2), number of pregnancies (-1.2), and history of bone fracture in past year(-2.9) were the more important determinants of physical aspect of HRQoL than other included variables of this study. Furthermore, age over than 60 (-9.1), history of bone fracture in past year(-4.8), weekly walking hours(2.3), marital status(-5), and education level (3.9)influenced the mental aspect of HRQoL.

Conclusions

Social and life style factors tend to impact on physical and mental domains of HRQoL, a measure that is influenced by multiple factors among postmenopausal women. In this respect, these obtained factors should be considered for health planning to improve the physical and mental domains of HRQoL among postmenopausal women.

The reliability and validity of the Turkish version of the Quality of Life Questionnaire of the European Foundation for Osteoporosis-31 (QUALEFFO-31)

This study reveals the Turkish version of QUALEFFO-31 has a sufficient level of reliability, validity, and psychometric properties. The questionnaire, which is potentially capable of differentiating patients with fractures, does not appear to have the differential capacity in terms of osteoporosis.

PURPOSE

This study aims to conduct the reliability and validity study of QUALEFFO-31 in Turkish and to evaluate the capacity of the questionnaire to distinguish patients in terms of osteoporosis.

METHODS

The original English version was translated into Turkish by two translators whose native language was Turkish. Subsequently, this Turkish version was translated back into English by two different bilingual translators whose native language was English. After this preliminary questionnaire was tested in 30 patients, words, terminology, information errors, and parts difficult to understand were revised, and the questionnaire was finalized. Internal consistency and test-retest analyses were used for the reliability study. For the validity study, convergent-discriminant validity, concurrent validity, factor analysis, known-group validity, and receiver operating characteristic (ROC) analyses were performed.

RESULTS

A total of 111 patients were evaluated. Internal consistency levels were optimal except for the mental function. ICC coefficients showed good retest reliability for all domains and total tests. The convergent and discriminant validity ratios for the mental function domain were 78% for both and 100% for the other domains. There was a moderate and good negative correlation between QUALEFFO-31 and SF-36 domains which had similar names. Exploratory factor analysis revealed 3 structures. However, there was a spread to the other factors in physical function domain items. Confirmatory factor analysis (CFA) markers were not at a very good fitting level except for the relative chi-square index. When CFA was performed according to the assumed model, the fitting level increased in all analyses. There was no significant differential capacity in terms of osteoporosis or fracture for either QUALEFFO-31 or SF-36.

CONCLUSION

The Turkish version of QUALEFFO-31 has a sufficient level of reliability, validity, and psychometric properties. Nevertheless, improvements in pain and mental function domains and some changes applying to the model may increase the psychometric capacity of the questionnaire. The questionnaire, which is potentially capable of differentiating patients with fractures, does not appear to have the differential capacity in terms of osteoporosis. CLINICALTRIALS.

GOV IDENTIFIER

NCT04259099 (date of registration: February 6, 2020).

Osteoporosis in East Asia: Current issues in assessment and management

The greatest burden of hip fractures around the world is expected to occur in East Asia, especially China. However, there is a relative paucity of information on the epidemiology and burden of fractures in East Asia. Osteoporosis is greatly under-diagnosed and under-treated, even among the highest-risk subjects who have already suffered fractures. The accessibility to bone densitometry, the awareness of the disease by professionals and the public, and the use and reimbursement of drugs are some of the areas which need improvement especially. Cost-effective analysis on screening strategy and intervention thresholds based on local epidemiology data and economic status are available only in Japan. In addition, clinical risk factor models for the assessment of fracture probability may be ethnic specific. Further research is needed to develop a cost-effective risk assessment strategy to identify high-risk individuals for screening and treatment based on local data. Moreover, inadequate calcium and vitamin D intake is still an issue faced by this region.

The reliability and validity of the simplified Chinese version of Male QUALEFFO-26

The aim of the study was to investigate the reliability and validity of Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-26) in male osteoporosis patients from Chinese population. The simplified Chinese version of Male QUALEFFO-26 was translated and adapted on the basis of QUALEFFO-31, which was assigned to the cases and controls together with SF-36. Reliability was assessed using the intra-class correlation coefficient (ICC) and Cronbach's α. Validity was assessed with Pearson's correlation analysis between the similar domains of the two questionnaires. Receiver operating characteristics (ROC) curve analysis was carried out to determine the ability of male QUALEFFO-26 to discriminate between cases and controls. The ICC was 0.83 for pain domain, 0.79 for mental domain and 0.81 for physical function. Cronbach's α of each domain ranged from 0.82 to 0.89. Pearson correlation coefficients indicated significantly high correlations between corresponding domains of QUALEFFO-26 and SF-36, with r ranging from -0.523 to -0.832. ROC analysis showed that all the domains of QUALEFFO-26 were significantly predictive of vertebral deformity, with the values of AUC ranging from 0.68 to 0.84. The simplified Chinese version of Male QUALEFFO-26 was a valid, reliable and repeatable instrument showing favorable psychometric characteristics. The questionnaire can be used in male osteoporosis patients from Chinese population.

Cross-cultural adaptation and validation of the osteoporosis assessment questionnaire short version (OPAQ-SV) for Chinese osteoporotic fracture females

The Osteoporosis Assessment Questionnaire Short Version (OPAQ-SV) was cross-culturally adapted to measure health-related quality of life in Chinese osteoporotic fracture females and then validated in China for its psychometric properties. Cross-cultural adaptation, including translation of the original OPAQ-SV into Mandarin Chinese language, was performed according to published guidelines. Validation of the newly cross-culturally adapted OPAQ-SV was conducted by sampling 234 Chinese osteoporotic fracture females and also a control group of 235 Chinese osteoporotic females without fractures, producing robust content, construct, and discriminant validation results. Major categories of reliability were also met: the Cronbach alpha coefficient was 0.975, indicating good internal consistency; the test-retest reliability was 0.80; and principal component analysis resulted in a 6-factor structure explaining 75.847 % of the total variance. Further, the Comparative Fit Index result was 0.922 following the modified model confirmatory factor analysis, and the chi-squared test was 1.98. The root mean squared error of approximation was 0.078. Moreover, significant differences were revealed between females with fractures and those without fractures across all domains (p < 0.001). Overall, the newly cross-culturally adapted OPAQ-SV appears to possess adequate validity and reliability and may be utilized in clinical trials to assess the health-related quality of life in Chinese osteoporotic fracture females.

Validation of the simplified Chinese version of the quality of life questionnaire of the European foundation for osteoporosis (QUALEFFO-31)

PURPOSE

To translate quality of life questionnaire of the European foundation for osteoporosis (QUALEFFO-31) into a simplified Chinese version, and test its reliability and validity in osteoporosis patients from mainland Chinese population.

METHODS

Postmenopausal osteoporosis women with history of vertebral fracture were included as cases, and age-matched healthy female were included as controls. All subjects were from mainland China. The simplified Chinese version of QUALEFFO-31 and SF-36 were assigned to the two groups. Reliability was assessed using kappa statistics of agreement for each item and the intra-class correlation coefficient (ICC). The internal consistency was assessed with Cronbach's α. Pearson's correlation was used to assess convergent and discriminant validity.

RESULTS

Overall, 66 cases and 66 age-matched controls were included. The ICC for the test-retest reliability ranged from 0.76 to 0.91. Cronbach's α for pain, physical function, and mental function domains were 0.94, 0.87, and 0.79, respectively. Convergent validity and discriminant validity showed that each correlation coefficient between score of each item with total score of related domain was higher than that with total score of unrelated domain. Pearson's correlation coefficients indicated significantly high correlations between corresponding domains of QUALEFFO-31 and SF-36.

CONCLUSIONS

The simplified Chinese version of the QUALEFFO-31 is a reliable and valid outcome measure of functional status in patients with osteoporosis. This Chinese version of the QUALEFFO-31 can be utilized for future clinical studies in mainland China.

Lifelong bound feet in China: a quantitative ultrasound and lifestyle questionnaire study in postmenopausal women

OBJECTIVE

The phenomenon of foot binding, also known as 'lotus feet', has an enduring and influential history in China. To achieve a man-made smaller foot size, lifelong foot binding may have had adverse effects on the skeleton. We investigated bone properties in postmenopausal women with bound feet, which may provide new information for developing countermeasures for prevention of fragility fractures.

DESIGN

Population-based cohort study.

PARTICIPANTS

This study involved 254 postmenopausal women aged 65-80, including 172 with bound feet and 82 age- and gender-matched control subjects, living in a remote region of China.

OUTCOMES

Anthropometric, SF-36 Lifestyle Questionnaire and heel quantitative ultrasound (QUS) data were collected for the whole study population. A small subset of two cases was also invited for assessment of bone mineral density and microarchitecture at the distal tibia using high-resolution peripheral quantitative CT (HR-pQCT) and gait and balance tests.

RESULTS

Women with bound feet had significantly lower QUS values than age-matched women with normal feet; this was supported by HR-pQCT data. However, SF-36 Questionnaire results did not reveal any statistically significant differences in any categorical responses, including physical functioning, general health vitality and physical component summary score, and number of previous fractures. No impairment of body balance was found in the small subset.

CONCLUSIONS

The man-made changes caused by foot binding led to reduced physical activity, making the subjects prone to osteoporosis. Women with bound feet and osteoporosis did not have a higher incidence of fragility fractures than controls. This might be explained by compensation in physical activity to improve body balance, implying the importance of improving or maintaining body balance in overall prevention strategies against fragility fractures.

Validation of the Quality of Life Questionnaire of the European Foundation for Osteoporosis-31 in Spanish postmenopausal women

OBJECTIVE

The Quality of Life Questionnaire of the European Foundation for Osteoporosis-31 (QUALEFFO-31) is a reliable and validated questionnaire that assesses quality of life in osteoporotic women. Our objective was to analyze the reliability and validity of the Spanish version of QUALEFFO-31 and its ability to discriminate between women with osteoporosis and women without osteoporosis in a Spanish postmenopausal population.

METHODS

One hundred eighteen women (aged 50-65 y) completed the Spanish version of QUALEFFO-31. Bone mineral density was measured by dual-energy x-ray densitometry. Internal consistency and test-retest reliability were analyzed. Concurrent validity of QUALEFFO-31 was evaluated using Spearman's rank correlation coefficient with the 36-item Short-Form Health Survey (SF-36). To determined responsiveness, we analyzed mean differences between osteoporotic and nonosteoporotic women and performed receiver operating characteristic curve analysis.

RESULTS

The Spanish version of QUALEFFO-31 has shown excellent test-retest reliability with a high intraclass correlation coefficient for all its domains, especially for the total score (0.988; P < 0.001), and good internal consistency with optimal Cronbach α values in all scales (0.70-0.90). In concurrent validity analysis, QUALEFFO-31 total score showed a high and negative correlation with several scales of the SF-36 (P < 0.001). In responsiveness analysis, significant differences in the pain (P = 0.002) and QUALEFFO-31 total score (P = 0.004) scales were found between osteoporotic and nonosteoporotic women. No differences in areas under the receiver operating characteristic curve were found between the QUALEFFO-31 and the SF-36 scales.

CONCLUSIONS

The Spanish version of QUALEFFO-31 has good internal consistency, concurrent validity, and test-retest reliability, with satisfactory general psychometric properties, and is a valid tool for discriminating between osteoporotic and nonosteoporotic postmenopausal women aged 50 to 65 years.

An outcome measure of functionality and quality of life in Iranian women with osteoporotic vertebral fractures: a validation study of the QUALEFFO-41

BACKGROUND

Osteoporosis is a very common disease and often results in vertebral fractures. The Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-41) is a tool to measure health-related quality of life in these patients. This study aimed to cross-culturally translate and validate the QUALEFFO-41 in Iran.

METHODS

This was a prospective clinical validation study. A forward-backward procedure was used to translate the questionnaire from English into Persian. The translation and cross-cultural adaptation were made in accordance with published guidelines. Patients were divided into two study groups according to the World Health Organization criteria: those with at least one vertebral fracture who had undergone surgery and those with osteoporosis and no fractures as a control group. All of the participants were assessed by both the QUALEFFO-41 and SF-36. The surgery group was asked to respond to the QUALEFFO-41 at two points in time: the pre- and postoperative assessments (6-month follow-up). To test reliability, the internal consistency was evaluated using Cronbach's alpha coefficient. Validity was evaluated by assessing convergent validity between the QUALEFFO-41 and SF-36 and item-scale correlations and discriminatory ability. Internal responsiveness of the QUALEFFO-41 to the clinical intervention (surgery) also was evaluated comparing patients' pre- and postoperative scores.

RESULTS

A total of 149 patients completed the questionnaire: 48 surgical patients and 101 as a control group. At the pre- and postoperative assessments, the QUALEFFO-41 showed adequate internal consistency in all domains (Cronbach's alpha of 0.71 to 0.81). Additionally, the correlation of each item with its hypothesized domain on the QUALEFFO-41 indicated acceptable results, suggesting that the items had a substantial relationship with their own domains. Further analysis also indicated that the questionnaire was responsive to change (P < 0.0001). Significant correlations existed between scores of similar subscales of the QUALEFFO-41 and SF-36 (P < 0.001).

CONCLUSIONS

The findings show that the Iranian version of the QUALEFFO-41 is a reliable and valid measure of functionality and quality-of-life evaluation among patients with osteoporotic vertebral fractures.

Validation of the Quality-of-Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-26) in Korean population

We aimed to evaluate the reliability and validity of the adapted Korean version of the Quality-of-Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-26). Translation/retranslation of the English version of QUALEFFO was conducted, and all steps of the cross-cultural adaptation process were performed. The Korean version of the visual analog scale measure of pain, QUALEFFO-26 and the previously validated Short Form-36 (SF-36) were mailed to 162 consecutive patients with osteoporosis. Factor analysis and reliability assessment by kappa statistics of agreement for each item, the intraclass correlation coefficient and Cronbach's α were conducted. Construct validity was also evaluated by comparing the responses of QUALEFFO-26 with the responses of SF-36 using Pearson's correlation coefficient. Factor analysis extracted 3 factors. All items had a kappa statistics of agreement greater than 0.6. The QUALEFFO-26 showed good test/retest reliability (QUALEFFO-26: 0.8271). Internal consistency of Cronbach's α was found to be very good (QUALEFFO-26: 0.873). The Korean version of QUALEFFO-26 showed good significant correlation with SF-36 total score and with single SF-36 domains scores. The adapted Korean version of the QUALEFFO-26 was successfully translated and showed acceptable measurement properties and, as such, is considered suitable for outcome assessments in the Korean-speaking patients with osteoporosis.

Quality of life measurements in patients with osteoporosis and fractures

To review all specific questionnaires regarding quality of life in osteoporosis and to describe their distinctive indications, we searched Medline, the Scientific Electronic Library Online database, and the Latin-American and Caribbean Health Sciences Literature database. Nine specific questionnaires related to osteoporosis quality of life were found: 1) the Women's Health Questionnaire, 2) Osteoporosis Quality of Life Questionnaire, 3) Osteoporosis Assessment Questionnaire, 4) Osteoporosis Functional Disability Questionnaire, 5) Quality of Life Questionnaire of the European Foundation for Osteoporosis, 6) Osteoporosis-Targeted Quality of Life Questionnaire, 7) Japanese Osteoporosis Quality of Life Questionnaire, 8) the 16-item Assessment of Health-Related Quality of Life in Osteoporosis, and 9) the Quality of Life Questionnaire in Osteoporosis (QUALIOST™). The Quality of Life Questionnaire of the European Foundation for Osteoporosis is the osteoporosis-specific questionnaire most commonly used in the literature. The Quality of Life Questionnaire of the European Foundation for Osteoporosis and the Osteoporosis Quality of Life Questionnaire are targeted more toward fracture assessment, and the Osteoporosis Functional Disability Questionnaire can be used for longitudinal studies involving exercise. In the present study, the authors summarize all of the specific questionnaires for osteoporosis and demonstrate that these questionnaires should be selected based on the objectives to be evaluated. Osteoporosis-specific quality of life questionnaires should be validated in the language of the country of origin before being used.

Translation and validation of the Farage Quality of Life (FQoL™) instrument for consumer products into traditional Chinese

The Farage Quality of Life™ questionnaire (FQoL™) was developed specifically to assess the impact of consumer products. The objective of this investigation was to achieve a Chinese language instrument. The FQoL™ underwent a forward and backward translation, with cognitive testing by 13 subjects. Slight modifications were made to the instrument, and an implementation study was conducted with 800 participants having a mean (±SD) age of 34.22 (±9.28) years. The subjects were randomly assigned to use 1 of 4 ultra absorbency pad products for the length of one menstrual cycle. Three pads (coded N, S and C) were products currently available on the retail market, a fourth (coded M) was an experimental product improvement on Product N. Subjects were asked to complete the FQoL™ once before (T1) and once after (T2) the start of their period, and the Least Square (LS) Means were determined. Within group comparisons for each item and FQoL™ subscale were conducted by comparing the LS Means for T1 vs. T2. Participants using Product N showed the highest number of significant (p<0.05) changes (11 items), demonstrating these subjects felt worse about items mainly in the subdomains for Emotions, Personal Pleasure, and Physical State. Participants using Product C showed significant changes in 7 items mainly in the subdomains for Emotion and Physical State. Participants using Product S and the experimental Product M showed significant changes in only 4 and 3 individual items, respectively. These were not associated with any particular domain or subdomain. Between group comparisons were conducted by comparing the LS Means for the T2 responses for each group. The group using Product N had LS Mean responses that were significantly worse than the group using Product M for the Emotion, Personal Pleasure and Physical State subdomains, the Energy/Vitality domain, and 2 individual items. The Product S group was worse than the Product M group for 2 individual items. The Product C group was worse than the Product M group for the Personal Pleasure and Physical State subdomains and 5 individual items. We found that the Chinese language FQoL™ detected changes in HRQoL during menstruation compared with before menstruation. Further, the measure was able to detect differences among groups of subjects using different menstrual protection products.

Validation of the osteoporosis quality of life questionnaire QUALEFFO-41 for the Serbian population

Background

Vertebral fractures could lead to reduced physical, social and mental functioning, and loss of personal independence. Therefore, during the treatment of osteoporosis, it has become necessary to examine the changes in everyday functioning, well-being and health related quality of life (HRQOL). To that effect, this study aims to translate, culturally adapt, and validate the Serbian version of Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-41) for patients with vertebral fractures.

Methods

Nine female patients with osteoporosis participated in the pre-validation study. A validation, case–control study included two groups of female patients: one that consisted of 50 female patients with osteoporosis, and with at least one vertebral fracture, and another one that consisted of 50 control patients with osteoporosis but without fractures. They completed the QUALEFFO-41 and the EuroQol group questionnaire with five dimensions (EQ-5D) twice within a month. The validation study examined internal consistency, concurrent validity, test-retest reliability, sensitivity and specificity.

Results

During the pre-validation study, three of the items in the QUALEFFO-41 were slightly changed. Afterwards, during the validation study, the statistically significant differences (adjusted for: age, duration of menopause, current employment and marital status) in the mean values of all domains and total scores between the groups were noted. For the case group, the internal consistency of the QUALEFFO-41 domains and of total questionnaire was above 0.70. The test-retest reliability was tested by the intraclass correlation coefficients (ICC) that were in range 0.87 – 0.96 for the case, and 0.15 – 0.83 for the control group. Correlations between the total scores of the QUALEFFO-41 and the EQ-5D health state value, for both groups were negative and statistically significant (r = -0.78, p<0.001 and r = -0.73, p<0.001, respectively). The QUALEFFO-41 had a better prediction of the value of HRQOL of cases compared to the generic questionnaire EQ-5D (the AUC difference was 0.099, p = 0.013).

Conclusions

The Serbian QUALEFFO-41 version is reliable, valid, sensitive and predictive for examinations of HRQOL in patients with prevalent vertebral fractures and can be used in further studies.

Impact of osteoporosis and vertebral fractures on quality-of-life. a population-based study in Valencia, Spain (The FRAVO Study)

Background

To describe the health related quality of life in a population sample of postmenopausal women over the age of 50 and resident in the city of Valencia (Spain), according to the presence/absence of osteoporosis and the severity of prevalent morphometric vertebral fractures.

Methods

A cross-sectional age-stratified population-based sample of 804 postmenopausal women of 50 years of age and older were assessed with the SF-12 questionnaire. Information about demographic features, lifestyle, clinical features, educational level, anti-osteoporotic and other treatments, comorbidities and risk factors for osteoporosis were collected using an interviewer-administered questionnaire and densitometric evaluation of spine and hip and spine x-rays were carried out.

Results

In the non-adjusted analysis, mild and moderate-severe vertebral fractures were associated with decreased scores in the SF-12 Physical Component Summary (PCS) but not in the Mental Component Summary (MCS), while densitometric osteoporosis with no accompanying fracture was not associated with a worse health related quality of life. In multivariate analysis worse PCS scores were associated to the age groups over 70 (-2.43 for 70-74 group and -2.97 for 75 and older), chronic conditions (-4.66, -6.79 and -11.8 according to the presence of 1, 2 or at least 3 conditions), obesity (-5.35), peripheral fracture antecedents (-3.28), hypoestrogenism antecedents (-2.61) and the presence of vertebral fracture (-2.05).

Conclusions

After adjusting for confounding factors, the physical components of health related quality of life were significantly lower in women with prevalent osteoporotic vertebral fractures than in women -osteoporotic or not- without vertebral fractures.