|Year : 2017 | Volume
| Issue : 3 | Page : 269-273
The WHOQOL-BREF: Translation and validation of the odia version in a sample of patients with mental illness
Nilamadhab Kar1, Sarada P Swain2, Suravi Patra3, Brajaballav Kar4
1 Black Country Partnership NHS Foundation Trust, Wolverhampton, United Kingdom; Quality of Life Research and Development Foundation, Bhubaneswar, India
2 Mental Health Institute, SCB Medical College, Cuttack, India
3 All India Institute of Medical Sciences, Bhubaneswar, India
4 KIIT University, Bhubaneshwar, India
|Date of Web Publication||14-Sep-2017|
Consultant Psychiatrist, Department of Psychiatry, Black Country Partnership NHS Foundation Trust, The Beeches, Penn Hospital, Wolverhampton, United Kingdom
Source of Support: None, Conflict of Interest: None
Background: The World Health Organization Quality of Life–BREF (WHOQOL-BREF) is a well-validated, cross-cultural, generic instrument to measure the quality of life, which is available in many languages. Objective: It was intended to translate and validate the WHOQOL-BREF in Odia, an Indian language. Materials and Methods: WHOQOL translation methodology was adopted that included forward and backward translation and contribution from bi- and monolingual individuals. A sample of adult patients attending psychiatric unit and their caregivers without mental illness completed the questionnaire. Psychometric properties of the Odia version including reliability, validity, and item's correlation with their assigned domains were assessed. Results: A total of 150 individuals were included in the study, comprising 91 patients and 59 caregivers as healthy controls. Validity as measured by known group's comparison produced significant result in all the four domains (physical health, psychological health, social relationships, and environment), overall quality of life and health. There was significant correlation of the questionnaire items with their original assigned domain scores. The internal consistency reliability was acceptable; Cronbach's alpha value for the whole scale was 0.81 and that for individual domains were physical health: 0.71, psychological health: 0.70, social relationships: 0.65, and environmental health: 0.71. Conclusion: The study presents the preliminary findings on the psychometric properties of the Odia version of WHOQOL-BREF and suggests that it has acceptable reliability and validity for use in clinical settings involving patients with mental illness.
Keywords: Odia, psychiatry, quality of life, translation, validation, WHOQOL-BREF
|How to cite this article:|
Kar N, Swain SP, Patra S, Kar B. The WHOQOL-BREF: Translation and validation of the odia version in a sample of patients with mental illness. Indian J Soc Psychiatry 2017;33:269-73
|How to cite this URL:|
Kar N, Swain SP, Patra S, Kar B. The WHOQOL-BREF: Translation and validation of the odia version in a sample of patients with mental illness. Indian J Soc Psychiatry [serial online] 2017 [cited 2019 Jul 18];33:269-73. Available from: http://www.indjsp.org/text.asp?2017/33/3/269/214599
| Introduction|| |
Measurement of quality of life (QOL) is relevant in health research not only for studying the impact of ill health but also as an outcome measure for interventions. Among many QOL measures available, World Health Organization Quality of Life-BREF (WHOQOL-BREF) is a well-validated, cross-cultural, generic questionnaire which has been used in various clinical situations.,, It is the shorter version of WHOQOL-100; however, it covers a broad range of facets which are divided into four domains: physical health, psychological, social relations, and environment. It is used in research involving various interventions and in different settings.
WHOQOL-BREF has been translated and validated in many languages including many Indian languages;,,, however, it is not available in Odia language. Odia is the dominant spoken and written language in Odisha, an Eastern state of India, with a population of over 43 million and it is also used by many nonresident Odias living in other states and abroad. There is a need for a generic QOL instrument in Odia language to be used in clinical assessments.
With this background, it was intended to translate and validate the Odia version of WHOQOL-BREF in a sample of patients, with a focus on those attending psychiatric services.
| Materials and Methods|| |
At the outset, permission was obtained from the WHO to translate WHOQOL-BREF. The translation of WHOQOL-BREF to Odia followed the process suggested in the WHOQOL translation methodology. Initially, WHOQOL-BREF was translated to Odia by two bilingual experts (NK and SP) independently. Then, two translators consulted closely about the translation process and derived an agreed version. The translation was discussed with a bilingual panel. All the members of the bilingual panel examined the original and translated documents, discussed, made modifications through consensus, and achieved concurrence for the translated document. It was decided to translate in such a manner that people with a knowledge of Odia language at a very basic level of reading and writing (e.g., primary level of education) should be able to use it.
In the next step, four monolingual individuals read and commented in an articulate way on the translated document regarding its comprehensibility. These monolingual persons had no education in English and two of them had no formal education. The comments made by monolinguals were discussed in a group moderated by SP from the bilingual panel. All the information from the discussion was noted.
The comments and suggestions received from the monolinguals were reviewed by the bilingual panel and were incorporated into the translated document where it was felt by the panel that these comments accurately reflected the meaning of the original document. The bilingual group read through the document, discussed any further inconsistencies, and amended the translated document where appropriate. The translated document in Odia was then back-translated to English by a professional translator. The original and back-translated documents were then reviewed and compared by the bilingual experts. There were few changes made to the Odia version based on the initial back translation to English to make it more easily understood by people with no formal education. This included using a second qualifying word within bracket. In question 1, along with the Odia word “gunamana” for quality, the word “quality” was mentioned within bracket in Odia letters as this word is commonly used in Odia language. In question 7, the Odia word for “concentrate” “ekaagrataa” was written along with a commonly used word describing the essence of it “mana sthira” within bracket. In question 26 for “negative feelings,” “nakaaraatmak anuvaba” was used within bracket. In the instruction lines, the word “standard,” which is commonly used and understood, was retained in Odia letters along with the translated word “jeebanara stara.” These changes helped to bring about the essence of the questions in Odia appropriately. This Odia version was again back translated and discussed. It was ensured that the final document was clearly comprehensible, conveyed the meaning of the original scale, and grammatically correct in Odia language. At the end of the process, the Odia version of WHOQOL-BREF was considered as accurate and equivalent by the translation project team.
The summary report of the translation process containing the details of the procedures followed and the translated materials were submitted to the WHO, as suggested in the translation methodology. Following this, the WHO accepted the translated scale and provided permission to undertake the validation study.
Odia version of the WHOQOL-BREF was administered to a sample of patients attending the Mental Health Institute, SCB Medical College, Cuttack, Odisha. Patients who were not able to participate in the study because of their mental state or who did not consent were not included. A group of their attendants/caregivers who did not have mental illness were also recruited as controls. Written informed consent was obtained from the participants. Anonymity of the responses was highlighted. Ethical approval for the project was obtained from the Research Ethics Committees of Quality of Life Research and Development Foundation and Mental Health Institute, Cuttack. The demographic details like age, gender, education, occupation, and marital status were collected. The questionnaire along with WHOQOL-BREF instrument was self-rated. However, the ability of the participants to read and write Odia was also checked and those who could not read or write Odia were offered help by reading out and in completing the form. Incomplete forms were excluded.
The scoring guideline for WHOQOL-BREF was followed to derive scores for the four domains (physical health, psychological health, social relationships, and environment). Psychometric properties of the WHOQOL-BREF Odia version were assessed using different statistical tests. Internal consistency was assessed using Cronbach's alpha for reliability of each of the four domains and for the full scale. Values equal to or greater than 0.70 were considered acceptable. Criterion related validity was assessed by correlating item and domain scores and it was expected that the items would correlate more strongly with their assigned domains. Pearson correlation (r) equal to or greater than 0.40 was considered satisfactory.
Discriminant validity was determined by the ability of the domain scores to discriminate between the mentally ill and the control group without mental illness. It was tested by comparing mean scores in the two groups, using t-tests. This feature was also assessed for the two general facet items of overall quality of life and health (items 1 and 2, respectively). In the known group's comparison, it was expected that the control group would have higher scores in the domains compared to the ill group. Statistical analyses were conducted using PASW statistics package (version 18, SPSS Inc., Chicago).
| Results|| |
There were 151 participants in the study; however, one was excluded because of inadequate data. There was no refusal to participate. The age range of the sample (n = 150) was 18–70 and the mean age was 36.7 ± 12.1 years. There were 61 females (40.7%) and 89 males (59.3%) with a mean age of 33.9 ± 9.6 and 38.6 ± 13.3 years, respectively (t = –2.32, P < 0.05). Most people were educated, with only 9.3% had no or informal education; 21.3% were educated up to primary, 34.7% high school, 24.7% college, and 10% had university level education. While 43.3% of the sample were working, 18.7% were unemployed, 2.7% retired, 6.7% students, and 28.7% were housewives.
There were 91 patients and 59 controls in the sample. There was no difference in the composition based on gender, educational levels, work, or marital status between the healthy control and mentally ill group; except that the mean age of the control (39.4 ± 12.3 years) was higher (P < 0.05) than that of the ill group (34.9 ± 11.7 years). Among the patients diagnostic distribution was schizophrenia 37.4%, other psychotic disorders: 9.9%, bipolar disorder: 28.6%, depressive disorders: 16.5%, and other disorders: 7.7%.
The proportion of missing data, floor, and ceiling effects were analyzed. There was no returned questionnaire with more than 20% missing data for the WHOQOL-BREF scale. Proportion of subjects scoring at the lowest level (floor effect) ranged from 0.7 to 15.3%, and those scoring at the highest level (ceiling effect) ranged from 0.7 to 40.0%. Considerable proportion of patients (22%) did not respond to question 21 on sexual activity; this included 18.0% females, 24.7% males; 16.9% healthy controls, 25.3% patients; 80% university educated, 35.1% college educated; 60% students and 66.7% of unmarried participants.
The internal consistency reliability (Cronbach's alpha) value for the full questionnaire was 0.805; and those for the domains are presented in [Table 1], along with mean values of the scores for each domain. The values were acceptable for all domains except for the social relationships.
Comparison between known groups is given in [Table 2]. Mean scores of each domain were more for healthy compared with the ill participants. The scores for the overall quality of life (item 1) and health (item 2) were also significantly better in healthy participants. The correlation between domains and the WHOQOL-BREF items is presented in [Table 3]. There was significant correlation of the items with their original assigned domain scores.
There was no significant difference in the domain scores between genders. The domain scores of the younger (18-40 years of age) were compared with older participants (age 41 years and above). They were comparable in all domains except for the environment where the younger ones had better (P < 0.05) score (12.8 ± 2.3) than that (11.8 ± 2.3) of older ones.
| Discussion|| |
The study intended to validate WHOQOL-BREF in Odia, an Indian language. The translation method followed the process suggested by the WHO; which has the advantage over straightforward forward and back translation. These included the review of the original and translated documents by the bilingual group and comments from the monolingual group about the translated document. Various issues that were observed during the translation process were addressed through this process leading to improved satisfaction in the Odia language version.
Issues during translation
It is recognized that the translation and validation of instruments across different cultures are faced with challenges., In this project, it was intended that the translated version of WHOQOL-BREF in Odia should be easily understandable for those at the lower or no formal educational level. This way it will have higher utility. This required that the Odia version should use colloquial terms rather than literal words that are less frequently used in day-to-day conversation or used mostly in academic spheres. This was achieved through repeated discussions and the active participation of monolinguals in the translation process. There were a few notable observations. The word “quality” is also understood as it is in Odia, so this was retained within a bracket along with the Odia term for it. The specific words for “negative emotions” were not easily understood by the monolinguals, as these are not commonly used in day to day conversations; so the words describing the essence of these words were used; however exact translation of these words were also provided within bracket which made it more focused.
Psychometric properties of the Odia language version
The results provided preliminary findings on the psychometric property of the Odia version. The mean scores of different domains of WHOQOL-BREF Odia version were significantly more in the healthy control compared with the ill, which suggested acceptable discriminant validity. Similarly the control group had significantly higher score of overall quality of life and general health. This is similar to reported observations in other validation studies.,
The internal consistency measured by Cronbach's alpha was at an acceptable range for the whole scale and domains except for social relationship. There are similar observations from other studies validating WHOQOL-BREF in different languages. The range of Cronbach's alpha for the domains in the field trials have been variable. There could be several reasons for this; the social relationships domain consisted of three items; and in one of them (item 21: sexual activity), a considerable proportion (22%) of participants in this study did not provide an answer. Although the confidential nature of the study was highlighted, it appears that many participants have not have felt comfortable to answer this question, mostly the unmarried participants probably secondary to the sociocultural setting. However, it was interesting to observe that greater proportion of participants with higher education levels did not respond. Appropriateness of this item for specific categories of respondents has been raised by another study.
It may be highlighted that the time frame of the questionnaire used for this project was four weeks. It is recognized that for particular kinds of research, QOL may be studied for different time frames. The codes of the items 3, 4, and 26 are reversed, and hence, that the higher scores mean better QOL. These points might be helpful while using the scale and analyzing the data in future research.
The study has a few limitations. The population of healthy control was not from the general population and their sample size was relatively small. It is known that providing care for the patients could be stressful which may adversely impact upon the QOL; so attendants or caregivers may not represent normal control. Future studies may consider larger population from general public as the healthy control. As mentioned earlier, a considerable proportion of sample did not respond to the question on sexual activity. It probably reflects the hesitancy of the people for sensitive questions; and the response rate may increase by specific reassurance about confidentiality.
| Conclusion|| |
The findings provided preliminary evidence about the psychometric properties of the questionnaire in Odia. The study suggested that the Odia version of WHOQOL-BREF may be reliably used in psychiatric settings. Further research is required involving larger sample of general population as a healthy control.
Authors wish to thank the World Health Organization for the permission to translate the WHOQOL-BREF scale to Odia language and conduct the validation study. Individuals who supported the project were: Sarat Rath, PhD, Professor of Odia Language, Utkal University, Vani Vihar, Bhubaneswar; Harish Chandra Kar, Geriatric Care and Research Organization; Sasmita Kar, MSc, PGDDE, Quality of Life Research and Development Foundation, Bhubaneswar; Urmila Sathia, MD, MRCOG, Retired General Practitioner and Specialist in Obstetrics and Gynecology, Cannock, UK; Sudipta Ranjan Singh, MD, Assistant Professor Forensic Medicine and Toxicology, All Indian Institute of Medical Sciences, Bhubaneswar; Sarojini Patra, Laxmi Sahoo, Purushottam Majhi, Dushasan Samal; Ajay Kumar Mishra, MD, Associate Professor; Bibhudutta Sahoo, MD, Postgraduate Trainee in Psychiatry; Suneeta Mishra, Sushree Sangita Behuria, Shreyasri Sahoo, Clinical Psychology Trainees, Mental Health Institute, SCB Medical College, Cuttack, Odisha, India. The project was supported by Quality of Life Research and Development Foundation, Bhubaneswar, India.
Financial support and sponsorship
Conflicts of Interest
The authors declare no conflicts of interest.
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[Table 1], [Table 2], [Table 3]