www.elsevier.es/ejpsy
ORIGINAL
ARTICLE
The
Dutch
Recovering
Quality
of
Life
questionnaire
(ReQoL)
and
its
psychometric
qualities
B.C.
van
Aken
a,∗,
E.
de
Beurs
b,c,
C.L.
Mulder
a,d,
C.M.
van
der
Feltz-Cornelis
eaDepartmentofPsychiatry,ErasmusMedicalCentre,EpidemiologicalandSocialPsychiatricResearchInstitute,Postbus2040,
3000CA,Rotterdam,TheNetherlands
bArkinGGZ,Klaprozenweg111,1033NN,Amsterdam,TheNetherlands
cInstituteofPsychology,LeidenUniversity,Wassenaarseweg52,2333AKLeiden,TheNetherlands dParnassiaPsychiatricInstitute,Rotterdam,TheNetherlands
eChairPsychiatryandEpidemiology,DepartmentofHealthSciences,HYMS,YBRI,UniversityofYork,York,HeslingtonYO105DD,
UnitedKingdom
Received20December2019;accepted14January2020
KEYWORDS QualityofLife; Recovery; ReQoL; Dutchvalidation Abstract
Backgroundandobjectives: Theemergenceoftherecoverymovementhasledtothe devel-opmentoftheRecoveringQualityofLifeQuestionnaire(ReQoL)intheUK.Thisstudyaimsto describeandevaluatetheDutchtranslation.
Methods:The ReQoL was administered in two samples: 62 students completed the ReQoL-20,MANSA,EQ-5D-5L,PHQ-9andGAD-7throughanonlinesurveylink.TheReQoLwastested for reliability andafirst impressionwas obtained ofconvergent and knowngroup validity. In addition,164patients withapsychotic disorderthatwere partofthe UP’Scohortstudy completedtheReQoL-10,PHQ9andGAD-7.
Results:The ReQoL-10 andReQoL-20showed to bereliable inthe studentsample andthe patient sample.Indicesoftheconvergent andknown-group validityshowed thattheReQoL waspredominantlyassociatedwithqualityoflifeandwasabletodistinguishbetweenscores ofpatientandstudentsamples.
Conclusion: TheDutchtranslationoftheReQoL-10andReQoL-20yieldedresultsinlinewith thoseoftheoriginalEnglishversion.
©2020Asociaci´onUniversitariadeZaragozaparaelProgresodelaPsiquiatr´ıaylaSaludMental. PublishedbyElsevierEspa˜na,S.L.U.Allrightsreserved.
∗Correspondingauthor.
E-mailaddress:b.vanaken@erasmusmc.nl(B.C.vanAken).
Background
Inmentalhealthcarefor patientswithseveremental dis-orders, there has been a shift of attention from clinical
https://doi.org/10.1016/j.ejpsy.2020.01.001
0213-6163/©2020Asociaci´onUniversitariadeZaragozaparaelProgresodelaPsiquiatr´ıaylaSaludMental.PublishedbyElsevierEspa˜na, S.L.U.Allrightsreserved.
outcomesandsymptomreductiontoqualityoflifeand func-tional outcomes.1,2 Many researchers and clinicians have
arguedthat outcome measurementof mental health care (MHC)shouldhaveabroaderfocusthanmerelyassessingthe severityofsymptomatologyofpsychiatricdisorders.3,4The
emergenceofthe recoverymovementledtoan increased attention for the assessment of (health related) quality of life. Quality of life used to be assessed with generic measures, like the EQ-5D-5L4 or with instruments
devel-opedspecifically for MHC, such asthe Lancashire Quality ofLife profile(LQLP), anditsshorter version,the Manch-ester Short Assessment of Quality of Life (MANSA).5 The
EQ-5D-5Lisastandardised,non-disease-specificshort self-reportquestionnaireandhasbeenusedextensivelyinboth generalhealthcareandmentalhealthcare6inmany
coun-triesincludingtheNetherlands.7Itmeasureshealth-related
qualityoflifeinmultiplepopulations.4
Inrecentyears,therecoverymovementhasgained trac-tionandhasinspiredthedevelopmentofa newmeasure, theRecoveringQualityofLife(ReQoL)questionnaire, under-taken by the ReQoL Scientific Group at the University of Sheffield. Especially a in the development of this instru-ment.Forexample,part oftheReQoL hasbeen basedon theCHIMEconceptualframeworkforrecovery,which iden-tifiesfivepartsof(personal)recovery:Connectedness,Hope andOptimism,Identity,MeaninginlifeandEmpowerment.8
The development of the ReQoL was done in five stages. Thefirststageconsistedofdevelopingthemesforthe ques-tionnaire. Thesethemes weredrawn fromreviews9,10 and
interviews with service users,11 after which the item-list
wasgenerated by service-users and the research team.12
The lastthreestages consisted oftesting and analyses to investigatethereliabilityandvalidityoftheReQoLfor ser-vice users in the United Kingdom.13 All stages were done
bya core team of researchers,who weresupported by a scientific group,an international advisorygroup, a stake-holders’ group andan expert service user group.14 There
aretwoversions: a 10-itemand a 20-itemscale, the lat-terencompassingmorewellbeingitems.Theinstrumenthas satisfactorypsychometricproperties:thereliability (inter-nalconsistency)forboththeReQoL-10andReQoL-20inthe UK has been shown in patient samplesto be˛=0.85 and ˛=0.90 respectively, with r=.98 correlation between the twoversions. Convergentvaliditywassupported bya cor-relationabover=0.80acrossdiagnosticgroups withother instrumentsmeasuringsimilarconstructs.Furthermore,the ReQoL appeared able to distinguish between clinical and generalpopulationsamples.13
IntheNetherlands, thereisan increasingattentionfor recovery beyond mere symptom reduction. Consequently, the assessment of quality of life has gained attention as well,15---17 and the patient perspective becomesmore and
moreimportant.18,19Thisissimilartotheideasand
theoret-icalbasis inthe UK.20,21 Hence, theReQoL,in avalidated
Dutch version, could be a worthwhile alternative to the EQ-5Dand the MANSA since they both have shown tobe problematicforuseinmentalhealthsamples.22,23For
exam-ple,theEQ-5D-5Lhasanemphasisonpainand(dis)ability3
and the MANSA has been found to bestrongly associated withdepressivesymptoms24---26andisnotalwaysshowntobe
sensitivetochangeofqualityoflife.27Therefore,we
trans-lated theReQoL intoDutch withconsentfrom the ReQoL
researchgroupand thisversionis endorsedastheofficial Dutchversion.
Theaimofthepresentstudyistoinvestigatethe psycho-metricqualitiesof theDutchReQoLversion bycomparing scores on the items and psychometric properties to the original English version of the ReQoL. We administered the ReQoL-20 to a convenience sample (university stu-dents).Convergentvaliditywasinvestigatedbycomparing theReQoLwiththeEQ-5D-5LandMANSA;divergentvalidity withthe PHQ-9 andGAD-7. Furthermore,we investigated scores inagroupofpatients withadiagnosis ofpsychotic disorderandtheassociationoftheirscoresontheReQoL-10 withthePHQ-9andtheGAD-7.
Methods
Studysample
Studentsample
In order toinvestigate the Dutch version, the ReQoLwas administeredtoaDutchsampleofuniversity-levelstudents. Allstudents(N=62)completedtheReQoL-20,theEQ-5D-5L, MANSA,PHQ-9andGAD-7inasinglesitting,andanswered additionalquestions about having anypsychological prob-lemsandreceivingtreatmentfortheseproblems,with88.7 % notreceivingany treatment. Ageand gender werealso assessed,withtheiragerangingbetween19and31,witha meanof23.5(SD=2.4).Furthermore,mostofthestudents were female (n=46). Recruitment wasdone anonymously through an internet-link, where they could complete the questionnairesinasinglesession.Thelinkwasbroughtto their attention through various Social Media and through variousUniversitynewschannels.
Patientsample
Furthermore,inordertotestdivergentvalidityinapatient population,theReQoL-10measurementsofparticipantsof theUP’ScohortstudywerecomparedtoPHQ-9andGAD-7 scores.UP’Sisacohortthatinvestigatesrecoveryfor peo-ple with psychosis. All current participants of the cohort studythatcompletedtheinterview(N=164)alsocompleted thethreequestionnaires,aspart ofthat largerinterview. Age, gender, educational level, diagnosis and country of birthwerealsoassessed.ParticipantsarerecruitedforUP’S at different MentalHealth Carecentres in variousteams specialised in in- and outpatient care. All patients were between18and65yearsofageandwereincareforhaving a psychoticdisorder, includingschizophrenia, schizoaffec-tivedisorder,delusionaldisorderorpsychosisnototherwise specified.Theinterviewswerecarriedoutbyseveral Flex-ibleAssertiveCommunityTreatment(FACT)teammembers in the South-Western part of the Netherlands from which they received treatment. The characteristics of the cur-rentparticipants ofthecohort,areshowninTable1.The meanagewas40.1(SD=11.8)atbaseline(range18---64)and 66.5 %were male. Furthermore,almost half ofthe group had adiagnosis ofschizophrenia (48.2%). Forthis group, symptomscoreswerecalculatedusingthePANSS-Remission scale. Thisscale scoresthreepositive,threenegativeand twogenericsymptomsonaonetosevenscale,withonenot having the symptom andseven having the symptom
com-Table1 Demographiccharacteristicsofthestudentandpatientsample.
Studentsample Patientsample
N % N %
Gender
Men 16 25.8 109 66.5
Women 46 74.2 55 33.5
Educationallevel
Primaryschool(normalorvocational) --- --- 32 19.5
Generalsecondaryeducation(lower,senior,pre-uni) --- --- 65 39.6
Highervocationaleducation 5 8.1 10 6.1
UniversityBachelor 16 25.8 --- ---UniversityMaster 41 66.1 15 9.1 Unknown --- --- 42 25.6 ReceivingCare No 55 88.7 0 0 Yes 7 11.3 164 100
pletelyinterferewithdailylife.Forthispatientsample,the meanPANSS-Rscorewas2.0(SD=0.78),withmeanpositive symptoms2.1(SD=1.1),negative2.2(SD=1.0)andgeneric 1.7(SD=0.9).Allindicateverylowsymptomatology.
DutchversionoftheReQoL
Translation
The ReQoLgroupprovideda licensefor translationof the ReQoLtotheofficialDutch versiontoCvdF-C.To develop theDutchversionoftheReQoL,thequalityofthetranslation isessential,withequivalence inbothtermsandmeasured constructs. Therefore,an extensive translation procedure wasfollowed.28,29First,atranslationfromEnglishintoDutch
wasmade by asmallworkgroup led byCvdF-C. Secondly, thisfirstversionwastranslatedbacktoEnglishbyanative speaker.AnydiscrepanciesbetweentheoriginalReQoLand thistranslationwerediscussedbytheworkgroupand,when assistancewasneeded,discussedwiththeoriginalSheffield workgroup. Discrepancies in interpretation or meaning of itemsledtosomerevisionsoftheDutchtranslation. Further-more,theEnglishversionoftheReQoLcontainsaquestion aboutphysicalsymptoms,thescoringofwhichisnot consid-eredintheoriginalscoringinstruction.IntheofficialDutch version,ascoringinstructionforthatquestionwasprovided aswell.Atechnicalreportonthetranslationprocesscanbe retrievedfromtheauthors.
ReQoLanditsconstructs
The ReQoLmeasures RecoveringofQuality ofLife for the lastweek. Therearetwoversions:a 10-itemand20-item version.The itemsof the 10-itemversionare thefirst 10 itemsofthe20-itemReQoL.Ofthe20-items,11itemsare positivelywordedandninearenegativelyworded.Forthe 10-itemversion,thisisfourandsix,respectively.Allitems arescoredonafive-levelscale,rangingfrom‘Noneofthe time’to‘Mostofthetime’.Forthepositivelywordeditems, scoringisfromzerotofourwhereasthenegativelyworded items are scored from four tozero. Forboth versions, a sumscore canbecalculatedwithhigherscores indicating
ahigherrecoveringofqualityoflife.12 Forthepurposeof
comparingbothversions,ahalf-scorewillbecalculatedfor theReQoL-20inthisstudy.
DuringtheearlystagesofthedevelopmentoftheReQoL, 7themeswereidentifiedasbeingimportantforrecovering qualityoflifeinMHC:Activity;belongingandrelationships; choice,controlandautonomy;hope;self-perception; well-being;physicalhealth.These7themeswereusedasabase to generate items.12 The ReQoL-20 version contains four
questionson activity (questions 1,3, 11 and 12), two on belongingand relationships (questions 2 and9), three on choice,controlandautonomy(questions4,7and15),twoon hope(questions6and8),2onself-perception(questions10 and14),7onwell-being(questions5,13,16,17,18,19and 20),and1onphysicalhealth.Thefirst10questionsofthe ReQoL-20,makeuptheReQoL-10andthereforeallthemes arerepresentedwithtwoquestions,exceptself-perception, well-beingand physical health, which arerepresented by a single question. CvdF-C and EdB were members of the internationalscientificadvisorygroup.
UKversionoftheReQoL
ToevaluatetheDutchtranslationoftheReQoL,comparison withtheoriginalUKversionofboththeReQoL-10and ReQoL-20is necessary.Validationandreliabilityfor theReQoL-10 and -20 have been established in the UK during the last threestagesofdevelopmentoftheReQoL.Forthereliability assessment, a sample of both patients (N=800) and gen-eralpopulationmembers(N=2000)wererecruitedthrough amarket researchcompany. The general population sam-ple was representative for the UK general population in age,gender,ethnicityandgeography.74%(N=595)ofthe patientsamplereportedacommonmentalhealthdisorder. Ofthem,78%reportedverypoortofairmentalhealth.61% ofthetotalsamplewasfemale.Halfofthegroupcompleted theReQoL-10,theotherhalfcompletedtheReQoL-20. Sub-setsofthepatient(N=141)andgeneralpopulation(N=350) completed a second measurement two weeks later. For validitypurposes,4266serviceuserswererecruitedthrough secondaryproviders,generalpracticesandvoluntary organ-isations,either face-to-face, bypost or throughan online
channel.Allserviceuserscompleteda40-itemset,inwhich the ReQoL-10 and ReQoL-20 were embedded previous to gettingtotheir final formats. Participants werefrom five diagnosticgroupsandwerewelldistributedacrossgroupsby age,gender,maritalstatus,mainactivityandethnicity.39% reportedgoodtoexcellentmentalhealthand32%reported poortoverypoorgeneralhealth.Allinformationhasbeen obtainedfrom Keetharuthet al.13 and the developmental
reportoftheReQoL.12 Othermeasures
EQ-5D-5LandMANSA
The EQ-5D-5L measures health-related quality of life of today4 with 5 items: mobility, self-care, usual activities,
painordiscomfort,andanxietyordepression30,31andcanbe
usedtocalculatequality-adjustedlife-years(QALYs).32 For
responding,allquestionshavefiveresponseoptions, rang-ingfrom‘noproblems(1)’to‘extremeproblems(5)’.The EQ-VASscale at the end,assesses the patients’self-rated healthonavertical0---100scale.33
QualityoflifewasmeasuredbyMANSA,whichisashort versionoftheLQLPspecificallydevelopedtocounter short-comings of the LQLP, such as time toadminister, change overtimeandcomprisesitemsbestsuitedtodiscriminate betweensamples.34Thereisa12-anda16-itemMANSA
ver-sionconsistingofonlysubjectiveitems,orofbothsubjective andobjectiveitems.Fouritemsinvestigateobjective qual-ity of life and 12 investigate subjective satisfaction with lifeasawhole,job,financialsituation,friendships,leisure activities,accommodation,personalsafety,peoplethatthe person lives with, familyand health. Forthis study, only the12 subjective itemsare used.Satisfactionis rated on a7-point scale ranging from1=‘‘could notbe worse’’ to 7=‘‘couldnotbebetter’’,andanoverallscoreofsubjective qualityoflifemaybecalculated.5,34,35
PHQ-9andGAD-7
ThePatientHealthQuestionnaire’sdepressionmodule (PHQ-9)isascreenerfordepressivedisorder36---38thatisvalidated
andusedinmultiplecountries.39---41Itisa9-itemself-report
questionnaire,witheachitemrepresentinga criterionfor major depressive disorder in the DSM-IV. They are anhe-donia, depressed mood, sleep problems, feeling tired, changeinappetite,negativeself-evaluation,concentration problems,psychomotorchangesandsuicidality.Each item assessesfrequencyofthesymptomoverthelasttwoweeks andisscoredfrom‘Notatall(0)’to‘Nearlyeveryday(3)’. Asumscoreisthencalculatedthatcanrangefrom0to27, withscores ranging from5 to9representingmild depres-sivesymptoms,10---14moderatedepressivesymptoms,and 15---27severedepressivesymptoms.42
TheGeneralizedAnxietyDisorder7-itemscale(GAD-7)is abriefself-report scaleshowntobevalidandefficientto screenforGAD.Itconsistsof7-itemsthatassessesfrequency ofanxietysymptomsoverthelasttwoweeks,withscoring rangingfrom‘Notatall(0)’to‘Nearlyeveryday(3)’.Atotal levelofanxietyseverityiscalculatedthatcanrangefrom 0to21,withscores rangingfrom5to9representingmild anxiety,10---14moderateanxiety,and15---21severeanxiety. Last,if any of theitems scores above0, a final question
isaskedonceonthedisablingeffectofthesymptom(s)in general.43
Convergentvalidity
TheReQoLisbasedon7-themes,whichareactivity, auton-omy, belongingandfriendships,hope, self-perceptionand well-being. The MANSA is based on life as a whole, a job,financialsituation,numberandqualityoffriendships, leisure activities,accommodation, personalsafety,people that the individual lives with, sex life, relationship with family,physicalhealthandmentalhealth.Eachquestionof the EQ-5D represents mobility,self-care, usual activities, painordiscomfort,andanxietyordepression.Comparison between the measurementsresultsin the hypothesis that correlationsbetweensomesubscalesmight behigherthan betweenothers.Anoverviewofthecomparisonisgivenin
Table2.Forexample,itisexpectedhighercorrelationswill be found between the ReQoL subscale ‘activity’ and the MANSA’s‘Leisureactivities’.Likewise,highcorrelationsare expectedtobefound betweentheReQoL‘Hope’subscale andthe MANSA’s ‘Lifeasawhole’.A highnegative corre-lation is expected tobe found between the same ReQoL subscaleandtheEQ-5Danxietyitem.
Analysis
SkewnessandkurtosisoftheReQoLitemswereconsidered andcomparedtotheEnglishoriginal.Threescoreswere cal-culated:theReQoL-20totalscore,theReQoL-10totalscore, andaReQoL-20halfscore;thislastscoreallowsfordirect comparison with the ReQoL-10 scores, as was also done in analyses of theReQoL UK version.Furthermore,scores forthephysicalquestionoftheReQoLwerecalculatedfor boththestudentandpatientsample.Cronbach’salphawas determined and inter-item correlations calculated. Pear-son’sproductmomentcorrelationcoefficientswereusedto get an impression of theconvergent validitybetween the ReQoL-20,EQ-5D-5LandMANSAinastudentpopulation. Fur-thermore,theReQoL-10andReQoL-20scores,aswellasthe PHQ-9andGAD-7for bothsampleswereassessed.Forthe PHQ-9andGAD-7,clinicalcut-off scores(≥10)wereused asdescribedbyKroenkeetal.42togetanimpressionofthe
knowngroupvalidity.AnalyseswillbedoneusingSPSS24.0.
Results
Basicpsychometrics
Withinthestudentsample,inspectionofthedistributionsof theindividual itemsrevealed asubstantialdeviationfrom thenormalcurveforitem16with75.8%oftherespondents choosingthemostextremeresponsecategory.The distribu-tionoftheitemstwoandsixwasskewedaswell,although lesssubstantial.Means,standarddeviations,skewnessand kurtosisandrangeofsummedscalescoresarepresentedin
Table 3 The meanand standard deviation for the ReQoL-10 and -20 (half score) in the student sample was 27.9 (SD=6.9) and 27.9 (SD=7.3) respectively. Forthe patient sample,inspectionoftheindividualitemsontheReQoL-10 showednosubstantialdeviations,althoughmostitemswere somewhatskewed.Item6showedtobemostskewed.For
Table2 ImpressionofthethemesoftheReQoLwithsubscalesofothermeasures.
ReQoL MANSA EQ-5D
Activity Leisureactivities Dailyactivities
Autonomy Job,Finances
Belongingandfriends Friendshipsandrelationshipswithfamily
Hope Lifeasawhole Anxiety/depression
Self-perception Self-care
Well-being Safety,Mentalhealthandaccommodation Mobility
Physicalhealth Physicalhealth Painanddiscomfort
Table3 DistributionofscoresontheReQoL.
N Mean SD Range Skewness Kurtosis
ReQoL-20(Scale0---80) 62 55.6 13.7 22-77 −.48 −.69
ReQoL-20(Scale0---40) 62 27.8 6.9 11-38.5 −.48 −.69
ReQoL-10(Scale0---40) 62 27.9 7.3 11-39 −.48 −.69
ReQoL-10(Scale0---40)a 164 25.5 7.7 0-40 −.67 .35
ReQoLPhysical(scale0---4) 62 3.0 1.0 0-4 −.85 .18
ReQoLPhysical(scale0---4)a 164 1.2 1.2 0-4 .62 −.49 a Patientsample.
thispatients’sample,onlytheReQoL-10totalscorecould becalculated,showingameanof25.5(SD=7.7).Meansare highercomparedtotheoriginal version,were the ReQoL-10wasshown tohave ameanof 21.99(SD=10.3)andthe ReQoL-20of21.63(SD=9.97).
Reliability
Cronbach’s’alphafor theReQoL-20inthestudentsample was˛=0.94(␣=0.93UKversion12).Furthermore,the
inter-itemcorrelationwasr=0.44(range=0.15to0.83)indicating sufficientassociationamongtheitems.Cronbach’salphafor theextractedReQoL-10was˛=0.90(˛=0.87UKversion12),
with an inter-item correlation of r=0.47 (range=0.17 to 0.83).Forthepatientsample,theCronbach’salphaforthe ReQoL-10itemswas␣=0.87(˛=0.92UK version15).Here,
the inter item correlations was r=0.40 (range=−0.03 to .67).
Convergentvalidity
Inthisstudy,onlystudentdatais availableforthe ReQoL-20,MANSA,andEQ-5D-5L.However,afirstimpressionofthe convergent validity can be obtained withthis group. The shortandlong version of theReQoLshow similar correla-tions,bothweresignificant (p<0.001)andallcorrelations were in the correct direction. Correlation between the ReQoL-10andReQoL-20wasr=0.97.Furthermore, psycho-metricproperties are similarbetween both versions. The ReQoL-10correlatedr=0.74(0.76afterdeletingthe phys-ical health subscale) with the MANSA and the ReQoL-20 showed a correlation of r=0.72 (0.75 after deleting the physicalhealthsubscale)withtheMANSA.Correlationswith theEQ-5D-5Lwerer=−0.58forbothandthusoveralllower thanthoseoftheReQoLwiththeMANSA.
Subscalesforallmeasureshavebeencalculated. Corre-lationsbetweenthethemesoftheReQoLandthethemesof theMANSAanditemsoftheEQ-5DareshowninTable4.
Although correlationsareoverall low,theredoes seem tobeapatternofcorrelationsasisexpected:highbetween similarconstructs and generallylower between dissimilar constructs.Forinstance,thecorrelationbetweentheReQoL theme autonomyand theMANSA life asawhole washigh (r=.78), as is the correlation between the same MANSA themeand theReQoLtotalscore(r=.79). Forthe EQ-5D, depression-anxiety correlated highly negatively with the ReQoL themes autonomy (r=−.71), hope (r=−.74), self-perception(r=−.71)andwell-being(r=−.81),andwiththe totalscoreoftheReQoL(r=−.81).Overall,thecorrelations ofthe MANSA theme ‘Life asa whole’were high withall themesoftheReQoL,aswerethecorrelationsbetweenthe MANSA’s‘Leisureactivities’andTotalscore,andallReQoL themes.
ThephysicalimpairmentontheReQoLshowedlow cor-relationswiththe MANSAphysical subscaleandsomewhat highercorrelationswiththeEQ-5DVASscaleandtheEQ-5D painanddiscomfortquestion(r=.41, r=.59andr=−0.65 respectively).Furthermore,correlationsbetweenthis ques-tionandallother subscalesof boththeMANSA andEQ-5D werelow.
Firstimpressionofknown-groupvalidity
TheReQoL-10andReQoL-20scoreswerehigherforthe stu-dentsamplethanforthepatientsample,althoughnotmuch. Therangeofscoresforthestudentswassmaller,indicating thattherewerenostudentrespondentswithaverylowQoL. AsmalltomediumCohen’sd (0.32)between thesamples wasfound.The ReQoL-20totalhalf scoreforthestudents wascalculatedforcomparisonandshowedalmostno
men-Table4 CorrelationsbetweenthethemesoftheReQoLandcorrespondingthemesonothermeasures.
ReQoLthemes MANSA EQ-5D
N=62 LA JF FR Li SMA PH Totalscore DA SC MOB ANX PD Totalscore
Activity .59 .39 .42 .68 .44 .26 .56 −.40 −.04a −.07a −.60 −.37 −.47
Autonomy .69 .50 .52 .78 .50 .44 .69 −.36 −.13a −.15a −.71 −.37 −.55
Belongingandfriendships .57 .24a .50 .64 .67 .37 .67 −.39 −.18a −.23a −.63 −.20a −.48
Hope .63 .30 .36 .67 .42 .24a .53 −.16a −.20a −.16a −.74 −.09a −.38
Self-perception .61 .32 .44 .64 .51 .23a .57 −.25a −.11a −.02a −.71 −.21a −.40
Well-being .64 .32 .46 .68 .62 .35 .66 −.34 −.25 −.24a −.81 −.25 −.59
Physicalhealth .44 .29 .43 .53 .27 .41 .48 −.40 −.13a −.21a −.21a −.65 −.46
Totalscore .73 .40 .53 .79 .68 .38 .72 −.39 −.19a −.18a −.81 −.31 −.58 aNon-significantcorrelations/LA=Leisureactivities, JF=Joband Finances,FR=Friendships and Relationshipswithfamily, Li=Life asawhole,SMA=Safety,MentalHealthandaccommodation,PH=PhysicalHealth,DA=DailyActivities,SC=Self-care,MOB=Mobility, ANX=Anxiety/Depression, PD=Pain and discomfort/correlationsinbold are thecorrelationsfor similarconstructs asmentioned in Table2/correlationsinitalicsarehigh(>.70)correlationsbetweendifferentconstructs.
Table5 Known---groupvalidityfortheReQoL.
ReQoL-10 ReQoL-20
n MeanSD RangeT p n MeanSD Range T p Studentsamplevspatientsample
Studentsample 62 27.917.3 11---39 6227.776.911---38.5
Patientsample 16325.487.8 0---40 −2.14.034 ---
---Comparingclinicalcut-offsusedinclinicalpractice PHQ-9clinicalversusnon-clinicalscorecompletesamplea
Clinical(score≥10) 68 18.757.1 0---34 1418.644.311---27
Non-clinical 15429.405.4 12---4011.04<0.0014830.444.920---38.58.15<0.001 GAD-7clinicalversusnon-clinicalscorecompletesamplea
Clinical(score≥10) 50 18.767.6 0---34 5 17.704.011---24.5
Non-clinical 16628.636.2 9---40 8.43 <0.0015129.805.515---38.54.76<0.001
aParticipantsdidnotfillintheReQoL-20.Therefore,scoresfortheseinthecompletesampleconsistsofthestudentsonly.
tionabledifferenceinmean andrangewiththeReQoL-10 scoresofthesamesample.OnlySDdifferedabit.Forthe entire sample (both students and participants),ReQoL-10 scoresforthePHQ-9clinicallyscoringsamplewaslowerthan forthosenon-clinical,asshown inTable5.Cohen’sd was 1.69forthePHQ-9groupsontheReQoL-10,andd=2.6for theReQoL-20.FortheGAD-7groups,Cohen’sdwas1.42for theReQoL-10 and2.5 for the ReQoL-20.The means were shown to a bit higher again compared tothe original UK study.Forexample,thePHQ-9clinicalsamplemeanonthe ReQoL-10was15.73(SD=7.53)andfortheReQoL-2015.23 (SD=7.08)intheUK.Forthenon-clinicalsample,thesewere 27.37(SD=6.83)and27.38(SD=6.57),respectively,which arelowerthanshowninTable5.
Discussion
Thisstudyreportedonthedevelopmentandevaluationof thetranslation of theofficialDutchversion of the Recov-ering Quality of Life questionnaire to Dutch. Translation of the ReQoL has been done according to international translation standards, with a translation and back trans-lation, involvement of a native speaker and a discussion and resolution of the discrepancies between the original
and back translations,leading to adjustments in the first Dutch translation.28,29 Someskewness on theitems shows
to be similar to the original ReQoL-20 measure, where the presence of some items showedto be redundant but were left in to assess concepts more extensively.16
How-ever, skewed distributionof responsesonitem16 showed tobeextreme duringanalyses. Thisitemrepresents anxi-etyandshowedskewnessascouldbeexpectedinasample ofhealthyrespondents.However,asimilarpatternonthis itemhasnotbeenseenforthegeneralpopulationinthe orig-inalReQoLvalidation13 andcurrentwordingdoes instigate
extreme answers. The item therefore lacks informational valueandwillberephrased.Although otheritemsshowed tobeskewedaswell,skewnessandkurtosisfortheseitems didnotsuggesttheyshouldberephrased.
Evaluation of the Dutch version of the ReQoL showed promising results.To start,reliabilityis showntobegood for the ReQoL-20 and the ReQoL-10 in a student sample andfortheReQoL10inapatientsample.Cronbach’salpha was similar to the original version on all occasions. Cor-relation between the two measures in a student sample washigh,which isalsoin line withthe originalvalidation study by Keetharuth et al.13 Furthermore, a first
theMANSA,butlowercorrelationswiththeEQ-5D.Although the original version showed higher correlations with the SWEMWBSandCORE-10,thecorrelationbetweentheMANSA and ReQoLwere satisfactory for asmall sample. Further-more, the discrepancy in time period per questionnaire (day, week, two weeks) may have suppressed the inter-correlations,whichcouldalsoexplainthelowercorrelations betweentheMANSAandtheReQoLcomparedtothe origi-nal.Highcorrelationswerefound betweentheReQoLand theEQ-5Danxietyscale,whichisinlinewiththemain cri-tiqueontheEQ-5Dthatitemphasizestoomuchonpainand disability.3ValidityoftheReQoLisfurthersupportedbythe
highcorrelationbetweentheMANSA‘lifeasawhole’item andtheReQoLtotalscore.Thesubstantialnegative correla-tionbetweenthemood/anxietyitemoftheEQ-5Dandthe themesofhope,self-perceptionandwell-being,showsthat theReQoLmeasuresthese‘oppositesofanxiety’well.
Convergentvaliditywasfirstsupportedbyincreasing cor-relationsbetweentheReQoLmeasureandtheMANSAwhen physical items of the MANSA were deleted. The increas-ingcorrelationsareinlinewiththenotionthattheReQoL measuresnon-physicaldomainsofhealth-relatedqualityof life,withlessemphasisonpainanddisability.Secondly,the ReQoLPhysicalhealthquestioncorrelatedhighwiththePain andDisabilityscale,theEQ-5DVASscaleandthetotalscore oftheEQ-5D.AllunderlinethattheReQoLisindeedmore focused on the non-physical domains of QoL and less on pain and disability. At the same time, it shows the need foraseparatephysicalquestionwithseparatescoring.The non-physicaldomainsofqualityoflifearemostrelevantfor patientsinMHCandthereforeshouldbethemaincore.
Surprisingly,theconveniencesampleinthisstudyshowed lower quality of life compared to the general population in the original English study. This could be explained by thenatureoftheconveniencesample,namelythesample consistingofstudents.Recentresearchshowedthatquality oflife islowcomparedtonon-studyingpeers,44 makingit
hardertodistinguishbetweenthemandthepatientgroup. However,animpressionoftheknown-groupvalidityshowed thattheReQoLisabletodistinguishbetweenclinical pop-ulations.Again,thesemeasuresshowsimilarresultstothe originalstudy.
Overall,thefindingsshowthatthisofficialDutchversion oftheReQoLisvalid.Furthermore,thecorrelationsbetween thephysicalhealthquestionandtheEQ-5Dshowsthe valid-ityandapplicabilityof thisquestion andsupportstheuse ofnormscoresforthisquestion.Overall,theseadvantages overexistingmeasures,alongwiththefactthattheReQoL wasdevelopedfromaserviceusers’perspective15makethe
officialDutchReQoLavaluableinstrumentforthe Nether-lands.
Limitations
Thereare severallimitations tothisstudy.A convenience sample was used to test the ReQoL and they were not be representative for the population given for example their dispersionof gender. Completedata for the patient population wasnot yet available, makingit impossible to calculatereliabilityoftheReQoL-20andtest-retestvalidity onboththeReQoL-10andReQoL-20inthisgroup.
Compari-sonbetweengroupsontheReQoLmeasures,aswellasthe useofclinicalcutoffinthisgroupmighthavebeen compro-mised by limitations in both the convenience sample and the patient sample. The convenience sample of students showedlowReQoLscoresingeneral,whichmightbearesult ofcurrentpressureonstudents.Thepatientpopulation,on theother hand,did show similarresults onthe ReQoL as comparedtotheoriginalversion,butalsoshowedtobea clinicallystablegroupwithalmostnosymptomatology.One might argue that this does influence their quality of life score.LiketheEnglishoriginal,thevalidationresultswere calculatedon the embedded ReQoL-10.In an ideal situa-tion,participantswouldberandomlyassignedtoeitherthe ReQoL-10ortheReQoL-20.Thiscanbedonewhendata col-lectionontheReQoL-20iscompleted.Theirmeasurescan thenbecomparedtothatofthecurrentpatientpopulation. Now,convergentvaliditycouldnotbefullycalculatedsince therewasnopatientdataavailablefor theReQoL-20,the MANSAandtheEQ-5D.Furthermore,thestudentpopulation wasexpectedtoscore higherthan thepatients´sample on qualityoflifemeasuresandwithasmallerrangeofscores whichlimitstheassociationwithotherQoLmeasures. How-ever,thelargepatientpopulationrecruitedacrossmultiple MHCorganizations,doesmakethissampleidealforuseof theReQoL.
Further
research
Although evaluation of the measure in a student sample, aswell asevaluationof the shortversion of themeasure inapatientpopulationhasshownsome promisingresults, furtherresearchisneeded.First,itisadvisedtostudythe Dutchversionof theReQoL-20in apatientpopulation, as wellasageneralpopulationsample.Althoughthelatterhas been done, gender diversity in the sample was low, with mostofthestudentsamplebeingfemale.Furthermore,due toongoingresearch,nodatawasavailabletoevaluate test-retestreliabilityinapatientsample,norwasitpossibleto fitabifactorCFAmodelinapatientsample,asisstandardin validationstudies.Comparisonwithstudiesontheoriginal UKversionoftheReQoLisadvised.
Ethical
considerations
Thisstudyhasbeenevaluatedandapprovedbythe accred-itedDutch MedicalEthical Trial Committee(METC) of the ErasmusMedicalCentre,aspartof theUP’Scohort study. Studentsprovideddigitalconsentaspartoftheonline ques-tionnaire.Allpatientsprovidedwritteninformedconsent.
Funding
TheUP’ScohortstudyisfundedbyallparticipatingMental health institutions and the governing body of the City of Rotterdam.
Conflict
of
interest
Acknowledgements
Prof.dr.ChristinavanderFeltz-Cornelisandprof.dr.Edwin deBeursweremembersofthescientificadvisoryboardof theReQoLgroup.Prof.dr.ChristinavanderFeltz-Cornelis was licensed to translate and validate the official Dutch version of the ReQoL-10 and ReQoL-20.We would like to thankthedifferentMentalHealthCareInstitutionsfortheir fundingandparticipationinthisstudy.Thefollowing insti-tutionsarepartofthisstudy:ParnassiaPsychiatricInstitute intheformofBavoEuropoort,AntesDeltaPsychiatric Cen-treandParnassiaPsychosisResearch,Emergis,Dijk&Duin, GGzBreburg,GGzDelfland,GGzOost-BrabantandStichting Pameijer.Furthermore,wewouldliketothankthe govern-ing body of the City of Rotterdam for their funding and cooperation.
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