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A Japanese version of the questionnaire

for quality of life measurement

ORIGINAL ARTICLE Annals of Cancer Research and Therapy

Kazue Yamaoka*1), Fumi Hayashi*2), Chikio Hayashi*3), Jifuji Misumi*4),

Shinichi Takezawa*5), Masuyo Maeda*6), Hiroshi Sato*7), Seizo Oe*7), Kyoji Ogoshi*8) and QOL Research Group

A self-administered, short Japanese version of a quality of life (QOL) questionnaire was devised. This questionnaire measured non-disease-specific QOL. It was devised on the basis of the working hypothesis that "attitude towards disease" (F) affects "state of disease" (D)

, and items related to both F and D were considered. The items were divided into two questionnaires, each of which included certain common key questions.

This artice presents the details of our strategy for developing a short Japanese questionnaire to measure non-disease-specific QOL.

Ann Cancer Res Ther 3 (1): 45-53, 1994/Received 14 Mar 1994, Accepted 22 Mar 1994

Key words: quality of life, snort puestionnaire hon-disease-specific, patient structure, Hayashi's quantification method III

Life expectancy has recently increased dramatically

not only in developed countries, but also in Japan.

Increased attention is now being given to the importance

of quality of life (QOL), and methods of QOL measure-

ment have accordingly been developed1).

The increase of chronic disease makes it difficult to

evaluate the effect of treatment over the short term and

necessitates the provision of long-term care. Considering

these changes in the nature of disease, QOL measures have become increasingly important in assessing the

effectiveness of medical care1～4). Recently, not only for

chronic disease patients5) and elderly patients6), but also

for cancer patients, QOL has achieved a more important

role in the medical (especially oncological) commu-

nity7～12). In clinical cancer trials, QOL measurement has

also become important as a key efficient parameter along

with survival 13,14).

Although a large number of studies have been perfor-

med on QOL questionnaires, little attention has been

given developing a non-disease-specific QOL question-naire for Japanese. In the present study, we developed a

short self-administered questionnaire for Japanese

patients to measure non-disease-specific QOL.

Quality of Life Research Groop

Quality of Life Research Groop has a multidisciplinary-membership drawn from the fields of medicine, psy-

chology, sociology, philosophy, nursing, economics, and

statistics. The study group was formed in 1985 and the

members are listed in the Appendix. The principal aim of

this group is to consider health-related QOL and the

members share a common interest in QOL measures. The

current study was conducted in order to develop a simple

QOL questionnaire.

Background, definition, and development strategy

We compiled over 300 questions to assess QOL from

1985 to 1990. At the same time, we tried to translate the

concept of QOL into Japanese and decided on the term "IKIGAI" . The scheme of the QOL questionnaire is

shown in Table 1; items are classified into physiological,

psychological, and environmental factors. In developing a QOL questionnaire, we felt that non-disease-specific

questions should form the core, so that the questionnaire could be modified with disease-specific questions as necessary. In the development process, we referred to

many other QOL studies5,7～9,13～17).

By taking the differences of national character between

Japan and English-speaking countries, we have made a

Japanese version of a non-disease-specific QOL question-

naire, and then have reduced the number of items in the

present study. This QOL questionnaire can also be used to measure QOL in healthy persons.

In this study, we adopted the following two working

hypotheses:

*1) School of Jurisprudence, Teikyo University *2) School of Humanity, Toyo Eiwa Womens' University

*3) Institute of Statistical Mathematics *4) Chikushi-Jyogakuen University *5) Rikkyo University

*6) Nursing Department, Tokai University *7) the deceased *8) Second Department of Surgery, School of Medicine, Tokai Univer-

sity Hiroshi Sato, Seizo Oe; deceased

Correspondence to: Kazue Yamaoka, Scool of Jurisprudence, Teikyo University, 359 Otuka, Hachioji, Tokyo 192-03, Japan

Annals of Cancer Research and Therapy Vol. 3 No. 1 1994 45

Table 1 The factors related to QOL

(1) The QOL of a patient is similar to that of a healthy

person.

© (2) QOL includes two main factors, i. e., "attitude to disease" (F) and "state of disease" (D), and with the changes of these factors the QOL of a patient also

changes.

Using these hypotheses, the Japanese questionnaire was constructed employing items related to both F and

D. Although QOL changes are systematic in patients,

they may be random in healthy persons. Because we

assessed QOL subjectively, the evaluation needed to be

done in a range of patient and normal groups.

Analysis

Construction of the questionnaire

There are generally three types of QOL measures. The

first type is a performance score, e. g. an activity score.

This type of measure is evaluated by a third party. The

second type of evaluation employs objective data such as

clinical findings. The third type is subjective evaluation

by the patient. The present QOL questionnaire belongs

Table 2 The QOL questionnaires

Table 3 Number of subjects.

46 Annals of Cancer Research and Therapy Vol. 3 NO. 1 1994

Fig. 1 Structure of disease state in the patients: Questionnaire A

(PDA, 17 items), scattergram of the first vector (horizonal axis) and the second vector (vertical axis)

Numbers in the figure correspond to those in Table 2 (cir-

cles: better. triangles: neutral. crosses: worse)

Fig. 2 Example of a uni-dimensional structure (Guttman scale)

in QIII

Table 4 Similarity of QOL questionnaire structure between the patients and healthy persons.

Correlation coefficients were calculated for PDA vs. NDA and

for PDB vs.

NDB using 14 items in bothe cases.

Fig. 3 Structure of disease state in the patients: Questionnaire B (PDB, 17 items), scattergram of the first vector (horizonal

axis) and the second vector (vertical axis)



to this third type. The subjects of our pretest were

patients with various diseases, so this limited the number of items in the questionnaire. Therefore, we divided the

items into two questionnaires (both including items

related to F and D), each of which contained the same

key questions.

Hayashi18) proposed that the Japanese have two uni-

que national characteristics. One is a unique view of interpersonal relations and the other concerns the num-

ber of categories in an item. In considering the Japanese

national character, a 3-point scale is appropriate , because many respondents select the neutral middle category even

if a 5-point scale is applied.

Subjects and methods

The subjects were inpatients and outpatients with

cancer and other diseases at Tokai University Hospital

as well as healthy persons (group N) such as business-

men, nurses, and doctors. The questionnaire for group N

included the same items as that for the patients , except


Fig. 4 Structure of disease state in the patients: selected items (PD, 14 items), scattergram of the first

vector (horizonal axis) and the second vector (vertical axis)



Fig. 5 Structure of disease state in the healthy persons: selected items (ND, 10 items), scattergram of the first




Table 5 Similarity between the score calculated

by QIII and the response score

Correlation coefficients were calculated for items common to

PDA vs. NDA and PDB vs. NDB in the patient or healthy person

groups.

for items related to disease and medical care. Because of

the limitation that a long questionnaire was not suitable

for the patients, we divided the items into two question-

naires (Questionnaire A and Questionnaire B). Both

questionnaires included the same 18 key questions. The items were classified into two groups related to D and F.

There were 30 items in Questionnaire A for inpatients

(IA), 30 items in Questionnaire B for inpatients (IB), 32 items in Questionnaire A for outpatients (OA), 28 items

in Questionnaire B for outpatients (OB), 22 items in

Questionnaire A for healthy persons (NA), and 20 items is Questionnaire B for healthy persons (NB).

For analysis, we combined inpatients and outpatients

together as a patient group (group P). For the items

related to D, we assessed 17 items of Questionnaire A for

group P and 14 items for group N, as well as 17 items of

Questionnaire B for group P and 14 items for group N. As the items relarted to F, we used 8 items of Question-

naire A for group P and 4 items for group N, as well as

10 items of Questionnaire B for group P and 5 items for

group N. (Table 2). The number of subjects in each group is summarized

in Table 3. The questionnaire was a self-administered

and the responses were written by the patient.

For statistical analysis, Hayashi's quantification

method III19,20) (QIII) was used to examine the structure

of the questionnaire and Spearman/Pearson correlation

coefficients were determined to examine the strength of

associations.

Analysis of D-related items,

(1) Structure Structure of Questionnaire A: QIII was used to confirm the structure of Questionnaire A and the follow-

ing results were obtained in the patient group (PDA: 17

items): the maximum latent root was 0.33, the second

was 0.20, and the third was 0.09. QIII analysis of these

data revealed that two dimensions were sufficient for

expressing the order of the items. A scattergram of the

48 Annals of Cancer Research and Therapy Vol. 3 No. 1 1994

Fig. 6 Structure of the attitude towards disease in the patients:

Questionnaire A (PFA, 8 items), scattergram of the first vector (horizonal axis) and the second vector (vertical axis)

Numbers in the figure correspond to those in Table 2 (circles: better. triangles: neutral. crosses: worse)

Table 6 The response scores of the patients and healthy persons.

Values indicate the mean (standard deviation) of 66 patients and

57 healthy persons.

category values corresponding to the maximum latent

root (the first vector; the horizontal axis) and the

category values corresponding to the second maximum

latent root (the second vector; the vertical axis) is shown

in Fig. 1 The items related to a "worse physical state"

were located around the origin while those related to a "worse psychological state" were located a way from the

origin in the negative direction. For instance, responses

such as "never forget the illness", "pain", "irritation", "cannot do any thing"

, and "melancholy" were located in this order from the origin in the negative direction. In

the positive direction, the items revealed a symmetrical

pattern with those in the negative direction. Thus, the items were distributed along a cup type curve.

Assuming a dichotomous set of responses like that

shown in Fig. 2, the structure revealed by QIII indicates

that the items eliciting positive or negative responses

Fig. 7 Structure of the attitude towards disease in the patients: Questionnaire B (PFA, 8 items), scattergram of the first

vector (horizonal axis) and the second vector (vertical axis) Numbers in the figure correspond to those in Table 2 (circles: better. triangles: neutral. crosses: worse)

Fig. 8 Structure of the attitude towards disease in the patients: selected items (PF, 8 items): scattergram of the first





Fig. 9 Structure of the final questionnaire items for the patients:

selected items (19, items): scattergram of the first




were respectively located in a positive or negative direc-

tion from the origin, while the items eliciting both

positive and negative responses were located around the origin as in a Guttman's Scalogram21). When the questi-

onnaire structure is of this type, we can express the grade

of QOL as an uni-dimensional scale using the first vector.

Furthermore, the selection of items becomes easy,

because the employment of items equally spaced along

the curve will maintain the original structure (or at least

maintain the same order among items). On this basis,

reduction of the questionnaire items was performed.

In order to express the original structure with fewer

items, we selected items based on the results of QIII

analysis of PDA, choosing items at equal intervals on the

curve. For Questionnaire A, we selected the items fromthe "worse direction" (negative direction; marked as x in

the figure) and corresponding items from the "better

direction" (positive direction; marked as o in the figure).

Thus, if two items were at a similar location in the worse

direction but had different locations in the better direc-

tion, we selected both items. Selection was continued

until the number of items was reduced to approximately

2/3 of the original. As shown in Fig. 1, items were

selected from each cluster located alnog the curve. In

total, 12 items were selected for PDA (Table 4).

In the healthy person group (NDA: 14 items), the

maximum latent root was 0.41 and the second was 0.28.

As was the case for PDA, we used the first and second

Fig. 10 Structure of the final questionnaire items for the healthy

persons: selected items (17, items): scattergram of the first vector (horizonal axis) and the second vector (vertical

axis)

Numbers in the figure correspond to those in Table

2 (circles: better. triangles: neutral. crosses: worse)

Fig. 11 Examination of the influence of wording: PDA: scatte-

gram of the old version (horizonal axis) and the new version (vertical axis)

When a category is located around the regression, it

denotes the agreement of each category of an item

between the old and new versions.

vectors for the interpretation of the questionnaire struc-

ture. The structure was also a clear cup type curve. In the

healthy person group, the items related to physical condi-

tion were limited to "nausea", "pain", "edema", and

"fatigue". The items which corresponded to a worse

physical state were located around the origin, while those

for a worse psychological state were located in the


negative direction from the origin. The items "dissatisfac-

tion", "anxity", "state of health", "melancholy", "annoy-

ance", and "worse sentiment" were located in order from

the origin in the negative direction. Eight items were

selected.

Structure of questionnaire B: In the patient group

(PDB: 17 items), the maximum latent root was 0.28, the second was 0.17, and the third was 0.14. We used the first

and second vectors and a scattergram is illustrated in Fig.

3. The questionnaire structure was very similar to that of

PDA, but the items in the negative direction varied.

Selection of items was carried out by basically the same

method as for PDA, except that the key questions already

selected for PDA were selected while ignoring the results

of PDB. As a result, 12 items were selected.

In the healthy person group (NDB: 14 items), the

maximum latent root was 0.30, the second was 0.16. and

the third was 0.11. We used the first and the second

vectors. The questionnaire structure was less regular than

that of NDA. However, the items related to physical condition, such as "fatigue", "melancholy", and "state of

health", were well ordered. In this case, 8 items were

selected.

In order to confirm the similarity of questionnaire

structure between the patient group and the healthy

person group, Spearman's rank correlation coefficients for the order of the first vector for the common 14 items

were calculated (PDA vs. NDA and PDB vs NDB,

respectively). This was done in both the positive and

negative directions for Questionnaire A and Question-

naire B, respectively. The results indicated that question-

naire structures were very similar, except for the negative

direction of Questionnaire B. This would be expected,

since there should be few responses in the worse direc-tion in the healthy person group.

(2) Structure obtained with the selected items Structure: In this analysis, subjects who answered

both Questionnaires A and B were used (P: 66, N: 57).

In the patient group (PD: 13 items), the maximum latent root was 0.37 and the second was 0.23. A scattergram of

the first and second vectors is shown in Fig. 4. Again, a

cup type curve is seen. The scattergram helps to define

the order of the items. In the positive direction, the least

important items were "better morbility" and "nausea".

More important items were "less discomfort (MUNE NO

TUKAE, in Japanese)" and "less loneliness". These were

followed in order by "do not think about illness", "more

satisfied", "better sentiment", "better physical condition", "less pain"

, "less irritation", and "able to do as one wishes". The most important items (indicating the best

condition) were "less anxiety" and "less tired".

On the other hand, the order of worse condition was

expressed by "cannot forget the illness", "pain", "irrita-

tion", and "tired", followed by "lack of mobility", "lone-

liness", "cannot do anything", "bad physical condition", "anxiety" , "discomfort", "nausea", and "unsatisfied". Finally, "worse sentiment" denoted the worst condition

(Fig. 4). In the healthy person group (ND: 10 items), the


However, the questionnaire structure was not a clear cup

type one and a definite order did not emerge (Fig. 5).

Scoring the responses: When the pattern of responses

forms a cup type curve, most of the information can be

explained uni-dimensionally, and the scores for each

item can be summed as a total score (the response score).

The response score was calculated as follows. A positive

response score was determined as the sum of the positive

responses and a negative response score as the sum of the

negative responses. A single response to a worse category

for an item added -1 to the negative response score, while a response to a better category for that item

added +1 to the positive response score. In the response

was neutral, nothing was added to either score. If this

questionnaire, the items had 3 categories (better, neutral, worse). The intervals between the categories in as item

could not always be equal, so the relative interval

between the category values determined by QIII might

differ for one item. Thus, there is no guarantee that the

categories were symmetrical in the positive and negative

directions. Since we cannot say that QOL is better expres-

sed by positive or negative items, we devised two scores.

For instance, we can use the negative response score for

the measurement of QOL in order to lessen the negative

factors impacting on a patient. In order to examine the response score correlations

with the sample scores calculated by QIII, Pearson corre-

lation coefficients were calculated (Table 5). The correla-

tion coefficients were comparatively high, except for the

positive response score of PF and the negative response score of NF.

Analysis of the attitude to disease

(1) Structure Structure of questionnaire A: For the patient

group (PFA: 8 items), the maximum latent root was 0.20 and the second was 0.18. A scattergram of the first and

second vectors is shown in Fig. 6. The structure was not

a cup type curve and the worse and better directions were

different, indicating that the structure of F could not be

expressed uni-dimensionally. Furthermore, some of the

responses were answered wrongly to what was originally

intended. Therefore, we removed these items and selected

3 items (Table 2). In the healthy person group, the same


items were selected.

Structure of questionnaire B: For the patient

group (PFB: 10 items), the maximum latent root was 0.28 and the second was 0.24. Some of the items followed

a cup type curve and others were parallel to the first

vector (Fig. 7). The latter items had many missing

answers. Four items were selected by this analysis. In the

case of the healthy person group, the same items were

selected.

(2) Structure obtained with the selected items For the patient group (PF: 8 items), the maximum

latent root was 0.37 and the second was 0.32. The items

in the positive direction varied in order and were cluster-

ed around the origin. In the negative direction, some

items such as "financial apprehension", "not optimistic",

and "bad company" formed a cluster, while other items

such as "anxious about illness", "unexpected by the

family", and "stress" made a separate cluster (Fig. 8).

In the healthy person group (NF: 6 items), the


The structure was vague and the attitudes were less

defined than in the patient group.

Practical short QOL questionnaire

(1) Structure A total of 19 items for the patients and 17 items for the

healthy person group were analyzed. The scattergrams

are shown in Fig. 9 and Fig. 10, respectively. The patient

group showed a cup type structure and the items related to F were located on the curve. This provides support for

the hypothesis that D might be influenced by F. Assum-

ing this hypothesis, the positive direction of category

values for F is constant, but when D and F are analyzed

together the category values of F will very according to

the state of D. On the other hand, the healthy person

group did not show a clear cup type structure. One explanation for this is that the QOL of these subjects was

more varied than that of the patient.

(2) Improvement of wording As some of the items were considered to be poorly

expressed, we next tried to improve the wording on the

basis of a survey of the Japanese language. Subsequently,

analysis was carried out to examine the effect of differ-

ences in wording between the old and new versions. In

order to do this, the second surver was conducted using

the new version of the questionnaire. The subjects were

only patients (107 for Questionnaire A and 106 for

Questionnaire B with 55 common). The structure was then compared with respect to the order of the items in

the first vectors of each questionnaire. Figure. 11 illus-

trates the differences between the old version (horizontal

axis) and the new version (the vertical axis) of Question-

naire A. When an item is located around the regression

line, it denotes the agreement of each vectors. It was

found that 4 items were influenced by the wording. A

similar comparison was also carried out for Question-naire B and for both questionnaires combined.

From the results of these comparisons, the items in the

questionnaire were confirmed. This questionnaire was designated as the short QOL questionnaire (QL-20) (it is

presented in Japanese in the Japanese Abstract).

Discussion

Life expectancy has increased dramatically in Japan.

The concept on QOL was developed in Western coun-

tries and the majority of the available QOL measures

have been developed in English-speaking countries,

primarily in the United States. In recent years, the necessity of assessing of QOL in patients with cancer and

other chronic diseases, or even in healthy individuals, has been stressed.

The measurement of QOL, as well as the measurement

of mortality and morbidity, now has an important role in the evaluation of treatment in clinical trials. However,

very different meanings were assigned to the concept of

QOL22) by different investigators and the concept also varies with type of illness, the bodily functions involved,

and the physical and emotional problems. Although

most people in Japan have an intuitive understanding of

the concept of QOL, it is difficult to define it and solve

the translation problems related to adapting foreign

questionnaires. Accordingly, we designed a Japanese

QOL questionnaire. Even the phrase "QOL" could not be translated ade-

quately into Japanese. From 1985, we have discussed a suitable translation of QOL and the problems of assess-

ment in the "QOL Research Group", and we eventually

expressed QOL in Japanese as "IKIGAI" (matter related

to one's life). QOL is a concept that is subject to multiple

viewpoints. Good QOL is usually expressed in terms of

satisfaction, contentment, happiness, fulfillment, and the

ability to cope. Thus, physical well-being, mental well-

being, social well-being, and activity were considered as

the usual factors of QOL.

Our QOL questionnaire included items related to these

factors. From a clinical point of view, it is important to

recognize the complex nature of the doctor-patient rela-

tionship and to develop a pragmatic strategy for

introducing QOL measurenent into clinical medicine.

Even in European countries, the process of producing

high quality translations of QOL questionnaire is

extremely complex. From the comparison of national

characteristics between Japan and the United States


performed by Hayashi18), many differences were highligh-ted such as family relationships. Therefore, we thought

that a translated version of an English questionnaire

would not adequately measure QOL in Japan, and thus

we devised the present questionnaire.

In construction of the QOL questionnaire, we consid-

ered the working hypothesis that "F affects D and the

QOL alters as D cahnges". Thus, the process of improve-ment of QOL can be described as follows. F is improved

by the intervention of medical and other staff, while D is

improved through cognitive behavior therapy and other

measures along with the improvement of F. Subsequently

the patient's QOL will improve.

There are several other questionnaires for the measure-

ment of QOL23～25) but their validity has not been suffi-

ciently examined. Because most of them were devised on

the basis of factor analysis, the additivity of the scores

was not assured. In the case of the present questionnaire,

however, the response score was calculated validly

because our scale was based on the result of QIII, from which additive relations result. However, some problems

still remain in relation to the questionnaire structure. For

example, it is unclear whether the structure is maintained when the severity of illness changes. When an illness

becomes more severe, it is possible that the structure of

QOL will change and that items related to the physical state will vary more. Thus, further study of this issue is

necessary.

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Appendix The other members of the "Quality of Life Research Group" Keizou Takemi, Mituko Satou, Kimiko Inao, Katsurou

Haruyama, Minoru Kurihara, Youko Ishihara, Kunihiko Kobayashi, Norio Satou, Takashi Takahashi, Jirou Mano Kunihiro Iwata.


Japanese version of questionnaire for quality of life

mesurement p 45～53

Kazue Yamaoka

本研究では,自記式簡易QOL調査票の日本語版の作成

を行った.この調査票は,患者の一般的な(疾患特有で

ない)QOLを測定するための調査票であり,疾患に関連

する態度(F)が病気の状態(D)に影響し,QOLが変

化するという作業仮説に基づいて作成されたものである.

調査票の作成に当っては,FとDのそれぞれに関連する

項目をスキームに応じて考えだした.この簡略化を,患

者を対象とした実際の調査から行った.すなわち,患者

を対象とした調査が可能なように,これらの項目をそれ

ぞれ共通の質問項目を含む短い二つの調査票にわけ,実

際の調査結果に基づき,数量化III類による構造分析を利

用して簡略化を行った.

本研究では,このような方法による一般的なQOLを測

定するための日本語版簡易調査票の作成方法について述

べる.

Annals of Cancer Research and Therapy Vol. 3 No. 1 1994

Ann Cancer Res Ther

a japanese version of the questionnaire for quality of …q-life.org/acrt/acrt03p045_053.pdfa...

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