Skip to main content
SpringerLink
Log in

A new look at the WHOQOL as health-related quality of life instrument among visually impaired people using Rasch analysis

  • Published:
Quality of Life Research Aims and scope Submit manuscript

Abstract

Purpose

To examine the psychometric characteristics of the World Health Organization Quality of Life instrument—modified Indian version (modified WHOQOL) and its subscales in adults with visual impairment (VI) using Rasch analysis.

Methods

Cross-sectional data were of people aged ≥40 years with VI (n = 1,333) who responded to the modified WHOQOL in the Andhra Pradesh Eye Disease Study, India. Rasch analysis was used to explore the instrument and its subscales for key indices such as measurement precision by person separation reliability, PSR (i.e., discrimination between strata of participants’ health-related QOL [HRQOL], recommended minimum value 0.8), unidimensionality (i.e., measurement of a single construct), and targeting (i.e., matching of item difficulty to participants’ HRQOL).

Results

Rasch-guided iterative approach including category re-organization to enable threshold ordering and item deletion to overcome multidimensionality resulted in a unidimensional 9-item WHOQOL and a 6-item level of independence (LOI) subscale with adequate PSR (0.81 and 0.82, respectively). Targeting was sub-optimal for both (−1.58 logits for WHOQOL and −2.55 logits for the subscale). Remaining subscales were dysfunctional.

Conclusions

The WHOQOL and LOI subscale can be improved and shortened, and the Rasch-revised versions are likely to assess the HROQL of VI patients best because of their brevity, reliability, and unidimensionality.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. WHOQOL Group. (1994). The development of the WHO quality of life assessment instrument (WHOQOL). In:J. Orley, W. Kukyen (Eds.), Quality of life assessment: International perspectives. Heidelberg: Springer.

  2. WHOQOL Group. (1993). Study protocol for the World Health Organization project to develop a quality of life assessment instrument (WHOQOL). Quality of Life Research, 2, 153–159.

    Article  Google Scholar 

  3. WHOQOL Group. (1994). Development of the WHOQOL: rationale and current status. International Journal of Mental Health, 23, 24–56.

    Google Scholar 

  4. Skevington, S. M., Lotfy, M., & O’Connell, K. A. (2004). The World Health Organization’s WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group. Quality of Life Research, 13(2), 299–310.

    Article  PubMed  CAS  Google Scholar 

  5. Saxena, S., Chandiramani, K., & Bhargava, R. (1998). WHOQOL-Hindi: a questionnaire for assessing quality of life in health care settings in India. World Health Organization Quality of Life. National Medical Journal of India, 11(4), 160–165.

    PubMed  CAS  Google Scholar 

  6. Bullinger, M., Anderson, R., Cella, D., & Aaronson, N. (1993). Developing and evaluating cross-cultural instruments from minimum requirements to optimal models. Quality of Life Research, 2(6), 451–459.

    Article  PubMed  CAS  Google Scholar 

  7. Dandona, R., Dandona, L., McCarty, C. A., & Rao, G. N. (2000). Adaptation of WHOQOL as health-related quality of life instrument to develop a vision-specific instrument. Indian Journal of Ophthalmology, 48(1), 65–70.

    PubMed  CAS  Google Scholar 

  8. Nutheti, R., Shamanna, B. R., Nirmalan, P. K., Keeffe, J. E., Krishnaiah, S., Rao, G. N., et al. (2006). Impact of impaired vision and eye disease on quality of life in Andhra Pradesh. Investigative Ophthalmology & Visual Science, 47(11), 4742–4748.

    Article  Google Scholar 

  9. Dandona, R., Dandona, L., Naduvilath, T. J., Nanda, A., & McCarty, C. A. (1997). Design of a population-based study of visual impairment in India: the Andhra Pradesh eye disease study. Indian Journal of Ophthalmology, 45, 251–257.

    PubMed  CAS  Google Scholar 

  10. Lee K., Ashton M. C. (2007). Factor analysis in personality research. In: R. W. Robins, R. C. Fraley, R. F. Krueger (Eds.), Handbook of research methods in personality psychology (pp. 424–443). New York, NY: Guilford Press.

  11. Gothwal, V. K., Wright, T. A., Lamoureux, E. L., & Pesudovs, K. (2009). Cataract symptom scale: clarifying measurement. British Journal of Ophthalmology, 93(12), 1652–1656.

    Article  PubMed  CAS  Google Scholar 

  12. Gothwal, V. K., Wright, T. A., Lamoureux, E. L., Lundstrom, M., & Pesudovs, K. (2009). Catquest questionnaire: re-validation in an Australian cataract population. Clinical & Experimental Ophthalmology, 37(8), 785–794.

    Article  Google Scholar 

  13. DeVellis, R. F. (2006). Classical test theory. Medical Care, 44, S50–S59.

    Article  PubMed  Google Scholar 

  14. Hambleton R. K. (2000). Emergence of item response modeling in instrument development and data analysis. Medicine Care 38(9 Suppl), II60–II65.

    Google Scholar 

  15. Pesudovs, K. (2006). Patient-centred measurement in ophthalmology–a paradigm shift. BMC Ophthalmology, 6, 25.

    Article  PubMed  Google Scholar 

  16. Andrich, D. A. (1978). A rating scale formulation for ordered response categories. Psychometrika, 43, 561–573.

    Article  Google Scholar 

  17. Bond, T. G., & Fox, C. M. (2001). Applying the Rasch model: fundamental measurement in the human sciences. London: Lawrence Erlbaum Associates.

    Google Scholar 

  18. Pallant, J. F., Miller, R. L., & Tennant, A. (2006). Evaluation of the Edinburgh Post natal Depression Scale using Rasch analysis. BMC Psychiatry, 6, 28.

    Article  PubMed  Google Scholar 

  19. Tennant, A., & Conaghan, P. G. (2007). The Rasch measurement model in rheumatology: what is it and why use it? When should it be applied, and what should one look for in a Rasch paper? Arthritis and Rheumatism, 57(8), 1358–1362.

    Article  PubMed  Google Scholar 

  20. Tennant, A., Penta, M., Tesio, L., Grimby, G., Thonnard, J. L., Slade, A., et al. (2004). Assessing and adjusting for cross-cultural validity of impairment and activity limitation scales through differential item functioning within the framework of the Rasch model: the PRO-ESOR project. Medical Care, 42(1 Suppl), I37–I48.

    PubMed  Google Scholar 

  21. Norquist, J. M., Fitzpatrick, R., Dawson, J., & Jenkinson, C. (2004). Comparing alternative Rasch-based methods vs raw scores in measuring change in health. Medical Care, 42(1 Suppl), I25–I36.

    PubMed  Google Scholar 

  22. Gothwal, V. K., Wright, T. A., Lamoureux, E. L., & Pesudovs, K. (2010). Activities of daily vision scale: what do the subscales measure? Investigative Ophthalmology & Visual Science, 51(2), 694–700.

    Article  Google Scholar 

  23. Gothwal, V. K., Wright, T. A., Lamoureux, E. L., & Pesudovs, K. (2009). Rasch analysis of visual function and quality of life questionnaires. Optometry and Vision Science, 86(10), 1160–1168.

    Article  PubMed  Google Scholar 

  24. Gothwal, V. K., Wright, T. A., Lamoureux, E. L., & Pesudovs, K. (2009). Visual activities questionnaire: assessment of subscale validity for cataract surgery outcomes. Journal of Cataract and Refractive Surgery, 35(11), 1961–1969.

    Article  PubMed  Google Scholar 

  25. Gothwal, V. K., Wright, T. A., Lamoureux, E. L., & Pesudovs, K. (2010). Measuring outcomes of cataract surgery using the Visual Function Index-14. Journal of Cataract and Refractive Surgery, 36(7), 1181–1188.

    Article  PubMed  Google Scholar 

  26. Pesudovs, K., Gothwal, V. K., Wright, T., & Lamoureux, E. L. (2010). Remediating serious flaws in the National Eye Institute Visual Function Questionnaire. Journal of Cataract and Refractive Surgery, 36(5), 718–732.

    Article  PubMed  Google Scholar 

  27. Dandona, L., Dandona, R., Naduvilath, T. J., McCarty, C. A., Nanda, A., Srinivas, M., et al. (1998). Is current eye-care-policy focus almost exclusively on cataract adequate to deal with blindness in India? Lancet, 351(9112), 1312–1316.

    Article  PubMed  CAS  Google Scholar 

  28. Dandona, L., Dandona, R., Naduvilath, T. J., McCarty, C. A., Srinivas, M., Mandal, P., et al. (1999). Burden of moderate visual impairment in an urban population in southern India. Ophthalmology, 106(3), 497–504.

    Article  PubMed  CAS  Google Scholar 

  29. Dandona, L., Dandona, R., Srinivas, M., Giridhar, P., Vilas, K., Prasad, M. N., et al. (2001). Blindness in the Indian state of Andhra Pradesh. Investigative Ophthalmology & Visual Science, 42(5), 908–916.

    CAS  Google Scholar 

  30. Dandona, R., Dandona, L., Srinivas, M., Giridhar, P., Prasad, M. N., Vilas, K., et al. (2002). Moderate visual impairment in India: the Andhra Pradesh Eye Disease Study. British Journal of Ophthalmology, 86(4), 373–377.

    Article  PubMed  CAS  Google Scholar 

  31. Ferris, F. L., 3rd, Kassoff, A., Bresnick, G. H., & Bailey, I. (1982). New visual acuity charts for clinical research. American Journal of Ophthalmology, 94(1), 91–96.

    PubMed  Google Scholar 

  32. Rasch, G. (1960). Probabilistic models for some intelligence and attainment tests. Copenhagen, Denmark: Institute of Educational Research.

    Google Scholar 

  33. Linacre, J. M. (2008). WINSTEPS Rasch measurement computer program. Chicago: Winsteps.com.

    Google Scholar 

  34. Wright, B. D., & Masters, G. N. (1982). Rating scale analysis. Chicago: MESA Press.

    Google Scholar 

  35. Gothwal, V. K., Wright, T. A., Lamoureux, E. L., & Pesudovs, K. (2009). Rasch analysis of the quality of life and vision function questionnaire. Optometry and Vision Science, 86(7), E836–E844.

    Article  PubMed  Google Scholar 

  36. Linacre, J. M. (2002). Optimizing rating scale category effectiveness. Journal of Applied Measurement, 3(1), 85–106.

    PubMed  Google Scholar 

  37. Pesudovs, K., Wright, T. A., & Gothwal, V. K. (2010). Visual disability assessment: valid measurement of activity limitation and mobility in cataract patients. British Journal of Ophthalmology, 94(6), 777–781.

    Article  PubMed  Google Scholar 

  38. Wright B. D. (1996) Reasonable mean-square fit values. In: B. D. Wright, J. M. Linacre (Eds.), Rasch measurement transactions (p. 370). Chicago: MESA.

  39. Linacre, J. M. (1998). Detecting multidimensionality: which residual data-type works best? Journal of Outcome Measurement, 2(3), 266–283.

    PubMed  CAS  Google Scholar 

  40. Smith, E. V., Jr. (2002). Detecting and evaluating the impact of multidimensionality using item fit statistics and principal component analysis of residuals. Journal of Applied Measurement, 3(2), 205–231.

    PubMed  Google Scholar 

  41. Linacre J. M. (2005).User’s guide to Winsteps. Chicago: MESA Press.

  42. Wright, B. D., & Stone, M. H. (1979). Best test design. Chicago: MESA Press.

    Google Scholar 

  43. Mallinson, T., Stelmack, J., & Velozo, C. (2004). A comparison of the separation ratio and coefficient alpha in the creation of minimum item sets. Medical Care, 42(1 Suppl), I17–I24.

    PubMed  Google Scholar 

  44. Mallinson, T. (2007). Why measurement matters for measuring patient vision outcomes. Optometry and Vision Science, 84(8), 675–682.

    Article  PubMed  Google Scholar 

  45. Pesudovs, K., Burr, J. M., & Elliott, D. B. (2007). The development, assessment and selection of questionnaires. Optometry and Vision Science, 84, 664–675.

    Google Scholar 

  46. Wright, B. D. (1996). Local dependency, correlations and principal components. Rasch Measurement Transactions, 10, 509–511.

    Google Scholar 

  47. Wright B. D. (1985). Additivity in psychological measurement. In: E. Roskam (Ed.), Measurement and personality assessment (pp. 101–112). Amsterdam: Elsevier Science.

  48. Svensson, E. (2001). Guidelines to statistical evaluation of data from rating scales and questionnaires. Journal of Rehabilitation Medicine, 33, 47–48.

    Article  PubMed  CAS  Google Scholar 

  49. Schipper H., Clinch J., Olweny C. L. M. (1996) Quality of life studies: Definitions and conceptual issues. In: B. Spilker (Ed.), Quality of life and pharmacoeconomics in clinical trials (pp. 11–23). Philadelphia: Lippincott-Raven Press.

  50. Rubin, G. S., Munoz, B., Bandeen-Roche, K., & West, S. K. (2000). Monocular versus binocular visual acuity as measures of vision impairment and predictors of visual disability. Investigative Ophthalmology & Visual Science, 41(11), 3327–3334.

    CAS  Google Scholar 

  51. West, S. K., Munoz, B., Rubin, G. S., Schein, O. D., Bandeen-Roche, K., Zeger, S., et al. (1997). Function and visual impairment in a population-based study of older adults. The SEE project. Salisbury Eye Evaluation. Investigative Ophthalmology & Visual Science, 38(1), 72–82.

    CAS  Google Scholar 

  52. Wang, J. J., Mitchell, P., Smith, W., Cumming, R. G., & Attebo, K. (1999). Impact of visual impairment on use of community support services by elderly persons: the Blue Mountains Eye Study. Investigative Ophthalmology & Visual Science, 40(1), 12–19.

    CAS  Google Scholar 

  53. Scott, I. U., Smiddy, W. E., Schiffman, J., Feuer, W. J., & Pappas, C. J. (1999). Quality of life of low-vision patients and the impact of low-vision services. American Journal of Ophthalmology, 128(1), 54–62.

    Article  PubMed  CAS  Google Scholar 

  54. Rovner, B. W., Zisselman, P. M., & Shmuely-Dulitzki, Y. (1996). Depression and disability in older people with impaired vision: a follow-up study. Journal of the American Geriatrics Society, 44(2), 181–184.

    PubMed  CAS  Google Scholar 

  55. World Health Organization (1948) World Health Organization constitution. In: Basic documents. Geneva: World Health Organization.

  56. Sloane M. E., Ball K., Owsley C., Bruni J. R., Roenker D. L. (1992) The visual activities questionnaire: Developing an instrument for assessing problems in everyday visual tasks. In: Nonivasive assessment of the visual system: 1992 (pp. 26–29). Technical Digest (Optical Society of America).

  57. Andersen, E. B. (1977). Sufficient statistics and latent trait models. Psychometrika, 42, 69–81.

    Article  Google Scholar 

Download references

Acknowledgments

The authors thank the participants for their participation in the study; Lalit Dandona and Rakhi Dandona for design and execution of the APEDS; and Nagaraj V. Naidu, Kovai Vilas, Pyda Giridhar, and Mudigonda N. Prasad for administering the questionnaires and the entire APEDS team for conducting the study. This study was supported by the Hyderabad Eye Research Foundation, Hyderabad, India.

Conflict of interest

The authors have no personal financial interest in the development, production, or sale of any device discussed herein.

Author information

Authors and Affiliations

  1. Meera and L B Deshpande Centre for Sight Enhancement, Vision Rehabilitation Centres, L. V. Prasad Eye Institute, Dr. Kallam Anji Reddy Campus, L. V. Prasad Marg, Banjara Hills, Hyderabad, 500034, Andhra Pradesh, India

    Vijaya K. Gothwal

  2. Bausch and Lomb School of Optometry, Hyderabad, India

    Vijaya K. Gothwal & Marmamula Srinivas

  3. International Centre for Advancement of Rural Eye Care, L. V. Prasad Eye Institute, Hyderabad, India

    Marmamula Srinivas & Gullapalli N. Rao

Authors
  1. Vijaya K. Gothwal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marmamula Srinivas
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Gullapalli N. Rao
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Vijaya K. Gothwal.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Gothwal, V.K., Srinivas, M. & Rao, G.N. A new look at the WHOQOL as health-related quality of life instrument among visually impaired people using Rasch analysis. Qual Life Res 22, 839–851 (2013). https://doi.org/10.1007/s11136-012-0195-6

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11136-012-0195-6

Keywords

Search

Navigation