Journal of Asthma, 29(6),39.3-399 (1992)
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A Life Activities Questionnaire for Adult Asthma Thomas L. Creer,' Joan K. Wigal,' Harry Kotses,' Karen McConnaughy,2 and John A. Winder2 Ohio University Athens, Ohio 'Allergy and Asthma Research Center Toledo, Ohio
ABSTRACT The development, testing, and applicability of an instrument, t h e Life Activities Questionnaire for Adult Asthma is described that can be used to assess activity restriction in adults with asthma. It explains how items for t h e instrument were selected to insure the validity of the developed instrument. T h e reliability of t h e questionnaire is also discussed. T h e result is a valid and reliable paper-and-pencil instrument that should have wide applicability as a component of quality of life measurement. This instrument has potential for functional use in clinical settings, research environments, and policymaking procedures.
INTRODUCTION
quality of usable measures o r instruments. Quality of life, health status, and similar terms are not synonymous; quality of life, in particular, is an inconsistently used and ill-defined concept. Instruments used to assess the variables of quality of life and health status are not interchangeable. Finally, cautions Lohr ( l ) , inferences drawn from the
I n the late 1980s, the concept of health status was expanded to include quality of life. Lohr (1) noted that neither health status nor quality of life is a fully developed concept; furthermore, neither concept has a body of literature that fully supports the range or 393 Copyright 0 1992 by Marcel Dekker, Inc
Creer et al.
J Asthma Downloaded from informahealthcare.com by McMaster University on 02/05/15 For personal use only.
394 application of these measures in biomedical research, policy making, or clinical practice may vary dramatically depending on what one believes he or she is measuring. Considering only quality of life, there is little agreement about the underlying basis of the concept or the theoretical framework represented by the measurements. There is agreement that a number of multidimensional concepts are required for any quality of life measure (1-4). The number of dimensions may vary from three to eight or more; Cella and Tulsky (3), for example, isolated 10 distinct dimensions of quality of life in their review of the literature. A category included in the majority of instruments concerns physical functioning. Physical functioning entails the performance of self-care skills, but, in addition, it involves the ability to perform everyday activities (2). The assessment of everyday activities is important in asthma because of the intermittent and variable nature of the disorder. The performance of daily activities can change and be restricted as a function of a patient’s asthma. The purpose of this study was to develop and evaluate an instrument to assess the performance of common life activities in adults with asthma. Measuring life activities would be a significant component in assessing the quality of life experienced by these patients.
METHOD Experiment I
The purpose of the first experiment was to develop a list of activities that might be restricted because of asthma. These items were used to construct a patient questionnaire. This procedure was performed to insure that valid items would be included in the resulting life activities instrument.
women completed the forms. The 90 patients comprised a representative sample of adults with asthma. To enhance the likelihood that patients would more freely list any activity they perceived as restricted because of their asthma, their anonymity was preserved. Patients were recruited for the study when they reported for their regularly scheduled appointments with an asthma specialist; items were gathered over a two-month period. PROCEDURE
An open-ended activity questionnaire was administered to the subjects. Instructions were provided as follows: Because of your asthma, you may be limited in some types of activities. Although you may still engage in these activities, you may feel that your asthma does not permit you to perform these events as often or with as much vigor as you would like. We are trying to determine what types of activities cause problems with individuals with asthma. On the lines below, please list any activity restricted by asthma in some way. You may continue to list items on the back of the form if you would like to include more than 10 activities. Thank you very much.
Patients listed anywhere from 1 to 11 items on the open-ended questionnaire; a total of 258 activities were reported. Considering the large number and wide range of items listed, only those activities listed by two or more individuals were selected for inclusion in the questionnaire. The items selected were listed by 2 to 26 patients; the average number of times an item was cited was 3.69. Activities were classified into seven categories: (a) physical; (b) work; (c) outdoor; (d) emotions and emotional behaviors; (e) home care; (f) eating and drinking; and (8) miscellaneous. The result was the 70-item Life Activities Questionnaire for Adult Asthma.
SUBJECTS Experiment I I
Subjects were 90 adults with asthma diagnosed in accordance with criteria established by the American Thoracic Society (5). The age range was 18-66 years; 45 men and 45
The purpose of Experiment I1 was to administer the developed questionnaire to a single group of subjects on two separate oc-
Life Activities Questionnaire for Adults casions. This test--retest procedure is commonly employed to establish the reliability of an instrument or procedure (6).
SUBJECTS The subjects were 46 adults with asthma diagnosed in accordance with guidelines of the >4merican Thoracic Society (5). The subjects age range was 18-68; the average age was 37.3 years.
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PROCEDURE All subjects were contacted by mail to enlist their participation in the study. If they agreed to participate, they were mailed a questionnaire packet that included a cover letter, the Life Activities Questionnaire for Adult Asthma, and a return postage paid envelope. Two weeks after the initial questionnaire was returned, subjects were mailed anotlher packet that included a cover letter, a Life Activities Questionnaire for Adult Asthma, and a return postage-paid envelope. All data were collected within a period of one month. The procedure permitted the collection of data for the purpose of determining test-retest reliability coefficients. The following instructions were provided with the 70-item questionnaire: Because of your asthma, you may be restricted in some types of activities. You may cut out some events entirely; others you may engage in sometimes but feel that your asihma does not permit you to perform these activities as often or with as much vigor as you would like. ‘The following items describe activities in which a number of adults with asthma have said they are totally or sometimes restricted from performing. Read each item and check if you were restricted in some way from engaging in that aciivity DURING THE PAST W E E K . Note the degree to which you believe you were restricted: TOTAL RESTRICTION, SEVERE RESTRICTION, MODERATE RESTRICTION, SOME RESTRICTION, or NO RESTRICTION. There are also blank spaces in each category for you to write in any activity in which you were restricted; again note the
395 degree to which you believe you were restricted in that activity.
Subjects were then asked to list the degree to which they were restricted using a 5-point scale a = total restriction, b = severe restriction, c = moderate restriction, d = some restriction, and e = no restriction.
RESULTS A Life Activities Questionnaire for Adult Asthma was developed as a result of the responses gathered from 90 patients in Experiment I. This 70-item questionnaire was administered to a second group of patients in Experiment 11. Data from this second experiment were analyzed using the SPSSx computer package (7). The Pearson product moment correlation between the first and second administrations of the Life Activities Questionnaire for Adult Asthma was r=.80. This was statistically significant beyond the . O 1 level of significance. The correlation, as well ils the manner in which items were obtained for the questionnaire, confirms the reliability of the questionnaire. Cronbach’s alpha (8), or the internal consistency of the questionnaire, was alpha = .96 for the first administration and alpha = .97 for the second administration. These results also demonstrate the reliability of the questionnaire, as well as reflecting that the instrument is internally consistent. Although the purpose of the study was to develop and test an activities Questionnaire for adults with asthma, data were provided with respect to the items responded to by the 46 subjects. This information provides an index of the type and level of restriction experienced by the subjects. The data were quantified in the following manner: (a) total restriction = 4; (b) severe restriction = 3; (c) moderate restriction = 2; (d) some restriction == 1; and (e) no restriction = 0. Patients either noted N.IA for not applicable or left items blank that did not apply to them. Mean scores for items in which patients were most restricted are reported in Table 1 for each administration and according to the seven categories of items. The table also depicts the
Creer et al.
396 Table 1
Percentage of Subjects and Their Scores on Selected Items in the Seven Categories on the Life Activities Questionnaire for Adult Asthma FIRST ADMl N ISTRATION
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ITEM
PERCENTAGE
Category I : Physical Activities Climbing stairs Exercising Wa Ik ing Hurrying too much Sexual activities Running/joggi ng Playing with children or grandchildren Category I / : Work Activities Overexertion/fatigue Heavy lifting Working around odorskhemicals Category / / I : Outdoor Activities Walking outside Being around vehicle exhaust fumes Encountering pet animals Shoveling snow Category / V : €motions and €motional Behaviors Laughing Stress Shouting Crying Category V : Home Care Vacuuming Dusting Working around perfumes, etc. Working around odors or smoke Working with household chemicals Category VI: Eating and Drinking Activities Drinking alcoholic beverages Eating foods with MSG Category VII: Miscellaneous Sleeping Being in a smoke-filled environment Taking a hot, steamy shower or bath Speaking Singing Visiting friends with pets
SECOND ADMINISTRATION
SCORE
PERCENTAGE
SCORE
98 96 96 96 89 76 76
.89 1.30 .70 1.27 .66 1.89 .54
98 93 96 93 91 72 76
.87 1.49 .75 1.21 .48 1.97 .48
89 85 80
1.37 1 .oo 1.84
85 78 80
1.38 1.05 1.84
89 85 80 74
1.34 1.77 1.30 1.68
89 80 78 65
1.12 1.32 1.25 .87
91 89 87 83
1.oo 1.34 1.05 .84
93 89 85 83
.71 1.12 1.03 .68
100 93 93 89 87
1.13 1.49 1.51 2.17 1.90
96 98 87 96 91
1 .oo 1.38 1.58 2.02 1.98
80 74
1 .oo .9 1
76 74
.9 7 .85
93 91 89 89 83 78
.8 1 2.67 .49 .5 1 .74 1.53
96 98 93 91 76 76
.6 1 2.51 .47 .38 .83 1.34
percentage of patients who endorsed particular items on the questionnaire. Category I, or physical activities, includes 21 items. Items reported by a majority of subjects as contributing to activity restriction included climbing stairs, exercising, wallung, hurrying too much, sexual activities, running/jogging, and playing with children or grandchildren. Items that caused the greatest
amount of restriction were running/jogging, exercising, and hurrying too much. As depicted in Table 1, these items sometimes resulted in some restriction to moderate restriction. Category I1 includes four work activities. The majority of subjects listed overexertion/ fatigue, heavy lifting, and working around odors or chemicals as restricting their activi-
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Life Activities Questionnaire for Adults ties. Working around chemicals or odors, overexertionifatigue, and heavy lifting led to the highest mean scores of activity restriction, respectively. These items also resulted in some restriction to moderate restriction. Category III contains 12 outdoor activities. Activities cited most by subjects as apt to be restricted by asthma included walking outside (several qualified their answer by saying this mainly occurred in cold weather), being around vehicle exhaust fumes, encountering pet animals, and shoveling snow. The mean level of restriction ranged from some restriction to moderate restriction. The decrease in the mean score for shoveling snow in the second administration of the questionnaire is attributable to the time of the year the questionnaire was administered (early spring), when shoveling snow is less likely to be thought of as a regular activity. This change reflects the sensitivity of the measure in detecting environmental changes that may lead to restriction of activity in patients. Category IV, which includes four items, is a different category than the others; the category includes emotions and emotional behaviors described by patients as interacting with their asthma forcing restricted activity. Emotions or emotional behaviors were reported by a high percentage of all subjects a s contributing to their restriction. Stress interacte'd most with asthma and produced the highest mean level of restriction. Fifteen items regarding home care are included in Category V. As noted in Table 1, items most regarded a s leading to activity restriction were vacuuming; dusting; working around perfumes, incense, and other household odors; working around odors or smoke; and working with household chemicals. Working around odors or smoke was credited with producing the greatest amount of activity restriction, followed by working with hou:sehold chemicals, working with perfumes, incense, and other household odors, dusiing, and vacuuming, respectively. Working around odors or smoke resulted in a mean restriction that fell between moderate and severe restriction. Category VI contains five items related to eating and drinking. The highest percentage of subjects listed drinking alcoholic bever-
397 ages as restricting their activities; a second item was eating foods with MSG. With respect to level of restriction, drinking alcoholic beverages and eating foods with MSG, respectively, were described as producing the greatest amount of restrictron. A number of respondents wrote that they attempted to avoid both alcohol or products with MSG. Avoidance of products with these chemicals likely contributed to the low mean score of restriction credited to either akohol or MSG. The final category of items, Category VII, is concerned with miscellaneous activities reported by patients; eight items are contained in this section. Those activities said to be restricted by asthma included sleeping, being in a smoke-filled environment, taking a hot, steamy bath or shower, speaking, singing, and visiting friends with pets. The two items credited with leading to the greatest levels of restriction were being in a smoke-filled environment and visiting friends with pets. Being in a smoke-filled environment, in fact, registered the highest mean level of restriction of all items. At the conclusion of each category of the questionnaire, several blank spaces were provided to permit patients to add an activity that they thought contributed to restricting their activities. This allowed patients to describe items that resulted in activity restriction which may have been unique to them and not covered by the questionnaire. A number of patients noted various activities, but these were covered in other sections of the questionnaire. Only one item was written in more than once: three respondents reported that premenstrual syndrome (PMS) interacted with their asthma and resulted in activity restriction. Consideri.ng their comments, PMS might be added a s an item according to the purposes for which the instrument is used in the future.
DISC USSlO N We described the development and testing of an activity restriction instrument for use with adults with asthma. In designing Life Activities for Adult Asthma, content validity was achieved by asking 90 patients to identify
Creer et al.
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398
activities they perceived as being limited, at various times and in varying degrees, by their asthma. The items the 90 individuals reported were included in the subsequent questionnaire, contingent on the fact that the items were reported as causing activity restriction by two or more people. The reliability and internal consistency of the resulting questionnaire was determined with an independent sample of 46 adults with asthma. Internal consistency proved high (alpha = .96 for the first administration and alpha = .97 for the second administration), and the onemonth test-retest reliability was sound (r = .80); thus, the Life Activities Questionnaire for Adult Asthma has solid psychometric properties for use with asthmatic adults. There are two potential uses of the questionnaire. First, the instrument would be useful in determining the extent to which a wide array of activities are perceived as restricted because of asthma. The 5-point rating scale permits changes ranging from no restriction to total restriction to be recorded; the instrument, therefore, is sensitive to changes that occur in patients over time. The sensitivity of the questionnaire would thus be valuable in making clinical, research, or policy-making decisions. A second use of the instrument is as a component in a battery of instruments developed and tested to assess quality of life in adults with asthma. Two approaches have been taken in developing quality of life instruments (4). One approach is to develop a global measure that can be used across diseases or disorders. There is merit to this approach as the impact of asthma on patients, for example, can be compared with the impact that other respiratory disorders have on patients. There are instruments available that provide global assessment, including the Quality of Well-Being Scale (9) and the Sickness Impact Profile (10). The question that arises with these instruments is whether they are applicable to patients with asthma because of the unique characteristics of the disorder (e.g., the intermittent and variable nature of asthma). Research has shown that the Quality of Well-Being Scale is useful with
patients with chronic obstructive pulmonary disease (11);ongoing research is evaluating use of the instrument with asthmatic adults. This should demonstrate whether the Quality of Well-Being Scale is useful in assessing the quality of life experienced by these patients. No one, as yet, has used the Sickness Impact Profile to any extent with asthma. The second approach is to develop a disorderspecific instrument. This tactic has been widely taken with other diseases, particularly cancer (3,4,12). A disadvantage is that global assessment is sacrificed with the approach. This can, in turn, make it difficult to compare the impact of asthma with the influence other diseases or disorders have on patients. The advantage of this approach is that an instrument or, more likely, a battery of instruments can be tailored to fit the unique characteristics of asthma. Ware (2) presented operational definitions of six health concepts that might be included in a battery of instruments designed to measure quality of life: physical functioning, mental health, social well-being, role functioning, general health perceptions, and symptoms. Specific instruments are available to assess most of these functions in adults with asthma. The Life Activities Questionnaire for Adult Asthma should become an integral component of a quality of life battery because it permits clinicians, investigators, or policy makers to determine the impact of asthma on the physical functioning of adults with the disorder.
ACKNOWLEDGMENT The authors thank Jennifer Creer Hatala for her help in collecting and collating the data. A copy of the complete Life Activities Questionnaire for Adult Asthma is available through the authors.
REFERENCES 1. Lohr KN. Conceptual background and issues in quality of life. In Quality of Life and Technology Assessment (Mosteller F, Falotico-Taylor J, editors), Washington, National Academy Press, 1989, pp. 1-6.
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Life Activities Questionnaire for Adults 2. Ware JE Jr. The assessment of health status. In Applications of Social Science to Clinical Medicine and Health Policy (Aiken LH, Mechanic D, editors), New Brunswick, NJ, Rutgers University Press, 1986, pp. 204-228. 3. Cella DF, Tulsky DS. Measuring quality of life today: Methodological aspects. Oncology 429-38, 1990. 4. Williams JI, Wood-Dauphinee S. Assessing quality of life: Measures and utility. In Quality of Life and Technology Assessment (Mosteller F, Falotico-Taylor J, editors), Washington, National Academy Press, 1989, pp. 65-115. 5. American Thoracic Society. Diagnosis standards for nontuberculosis diseases: Definitions and classifications of chronic bronchitis, asthma, and pulmonary emphysema. A m Rev Respir Dis 85:762-768, 1962. 6. Ysseldyke JE, Marston D. Issues in the psychological evaluation of children. In Handbook of Developmental and Physical Disabilities (Hasselt VBV, Stain PS, Herson M, editors.), New York, Pergamon Press, 1988, pp. 21-37.
399 7. SPSS. SPSS-X User's Guide, 3rd ed. Chicago: Author, 1988. 8. Cronbach LJ, Gleser GC, Nanda H, Rajaratnam N. 'The Dependability of Behavioral Measurements. New York, Wiley, 1972. 9. Kaplan RM, Atkins CJ, Timms R. Validity of a Quality of Well-Being Scale as an outcome measure in chronic obstructive pulmonary disease. / Chron Dis 37:85-95, 1984. 10. Bergner M, Bobbitt RA, Carter WB, Gilson BS. The Sickness Impact Profile: Development and final revision of a health status measure. Med Care 19:787805, 1981. 11. Atkins CJ, Kaplan RM, Timms RM, Rinsch S, Loftback K. Behavioral programs for exercise compliance in COPD. / Consult Clin Psycho1 52:591-603, 1984. 12. Falotico-Taylor J, McClellan M, Mosteller F. The use of quality-of-life measures in technology assessment. In Quality of Life and Technology Assessment (Mosteller F, Falotico-Taylor J, editors), Washington, DC,National Academy Press, 1989, pp. 7-43.
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A Life Activities Questionnaire for Adult Asthma Thomas L. Creer,' Joan K. Wigal,' Harry Kotses,' Karen McConnaughy,2 and John A. Winder2 Ohio University Athens, Ohio 'Allergy and Asthma Research Center Toledo, Ohio
ABSTRACT The development, testing, and applicability of an instrument, t h e Life Activities Questionnaire for Adult Asthma is described that can be used to assess activity restriction in adults with asthma. It explains how items for t h e instrument were selected to insure the validity of the developed instrument. T h e reliability of t h e questionnaire is also discussed. T h e result is a valid and reliable paper-and-pencil instrument that should have wide applicability as a component of quality of life measurement. This instrument has potential for functional use in clinical settings, research environments, and policymaking procedures.
INTRODUCTION
quality of usable measures o r instruments. Quality of life, health status, and similar terms are not synonymous; quality of life, in particular, is an inconsistently used and ill-defined concept. Instruments used to assess the variables of quality of life and health status are not interchangeable. Finally, cautions Lohr ( l ) , inferences drawn from the
I n the late 1980s, the concept of health status was expanded to include quality of life. Lohr (1) noted that neither health status nor quality of life is a fully developed concept; furthermore, neither concept has a body of literature that fully supports the range or 393 Copyright 0 1992 by Marcel Dekker, Inc
Creer et al.
J Asthma Downloaded from informahealthcare.com by McMaster University on 02/05/15 For personal use only.
394 application of these measures in biomedical research, policy making, or clinical practice may vary dramatically depending on what one believes he or she is measuring. Considering only quality of life, there is little agreement about the underlying basis of the concept or the theoretical framework represented by the measurements. There is agreement that a number of multidimensional concepts are required for any quality of life measure (1-4). The number of dimensions may vary from three to eight or more; Cella and Tulsky (3), for example, isolated 10 distinct dimensions of quality of life in their review of the literature. A category included in the majority of instruments concerns physical functioning. Physical functioning entails the performance of self-care skills, but, in addition, it involves the ability to perform everyday activities (2). The assessment of everyday activities is important in asthma because of the intermittent and variable nature of the disorder. The performance of daily activities can change and be restricted as a function of a patient’s asthma. The purpose of this study was to develop and evaluate an instrument to assess the performance of common life activities in adults with asthma. Measuring life activities would be a significant component in assessing the quality of life experienced by these patients.
METHOD Experiment I
The purpose of the first experiment was to develop a list of activities that might be restricted because of asthma. These items were used to construct a patient questionnaire. This procedure was performed to insure that valid items would be included in the resulting life activities instrument.
women completed the forms. The 90 patients comprised a representative sample of adults with asthma. To enhance the likelihood that patients would more freely list any activity they perceived as restricted because of their asthma, their anonymity was preserved. Patients were recruited for the study when they reported for their regularly scheduled appointments with an asthma specialist; items were gathered over a two-month period. PROCEDURE
An open-ended activity questionnaire was administered to the subjects. Instructions were provided as follows: Because of your asthma, you may be limited in some types of activities. Although you may still engage in these activities, you may feel that your asthma does not permit you to perform these events as often or with as much vigor as you would like. We are trying to determine what types of activities cause problems with individuals with asthma. On the lines below, please list any activity restricted by asthma in some way. You may continue to list items on the back of the form if you would like to include more than 10 activities. Thank you very much.
Patients listed anywhere from 1 to 11 items on the open-ended questionnaire; a total of 258 activities were reported. Considering the large number and wide range of items listed, only those activities listed by two or more individuals were selected for inclusion in the questionnaire. The items selected were listed by 2 to 26 patients; the average number of times an item was cited was 3.69. Activities were classified into seven categories: (a) physical; (b) work; (c) outdoor; (d) emotions and emotional behaviors; (e) home care; (f) eating and drinking; and (8) miscellaneous. The result was the 70-item Life Activities Questionnaire for Adult Asthma.
SUBJECTS Experiment I I
Subjects were 90 adults with asthma diagnosed in accordance with criteria established by the American Thoracic Society (5). The age range was 18-66 years; 45 men and 45
The purpose of Experiment I1 was to administer the developed questionnaire to a single group of subjects on two separate oc-
Life Activities Questionnaire for Adults casions. This test--retest procedure is commonly employed to establish the reliability of an instrument or procedure (6).
SUBJECTS The subjects were 46 adults with asthma diagnosed in accordance with guidelines of the >4merican Thoracic Society (5). The subjects age range was 18-68; the average age was 37.3 years.
J Asthma Downloaded from informahealthcare.com by McMaster University on 02/05/15 For personal use only.
PROCEDURE All subjects were contacted by mail to enlist their participation in the study. If they agreed to participate, they were mailed a questionnaire packet that included a cover letter, the Life Activities Questionnaire for Adult Asthma, and a return postage paid envelope. Two weeks after the initial questionnaire was returned, subjects were mailed anotlher packet that included a cover letter, a Life Activities Questionnaire for Adult Asthma, and a return postage-paid envelope. All data were collected within a period of one month. The procedure permitted the collection of data for the purpose of determining test-retest reliability coefficients. The following instructions were provided with the 70-item questionnaire: Because of your asthma, you may be restricted in some types of activities. You may cut out some events entirely; others you may engage in sometimes but feel that your asihma does not permit you to perform these activities as often or with as much vigor as you would like. ‘The following items describe activities in which a number of adults with asthma have said they are totally or sometimes restricted from performing. Read each item and check if you were restricted in some way from engaging in that aciivity DURING THE PAST W E E K . Note the degree to which you believe you were restricted: TOTAL RESTRICTION, SEVERE RESTRICTION, MODERATE RESTRICTION, SOME RESTRICTION, or NO RESTRICTION. There are also blank spaces in each category for you to write in any activity in which you were restricted; again note the
395 degree to which you believe you were restricted in that activity.
Subjects were then asked to list the degree to which they were restricted using a 5-point scale a = total restriction, b = severe restriction, c = moderate restriction, d = some restriction, and e = no restriction.
RESULTS A Life Activities Questionnaire for Adult Asthma was developed as a result of the responses gathered from 90 patients in Experiment I. This 70-item questionnaire was administered to a second group of patients in Experiment 11. Data from this second experiment were analyzed using the SPSSx computer package (7). The Pearson product moment correlation between the first and second administrations of the Life Activities Questionnaire for Adult Asthma was r=.80. This was statistically significant beyond the . O 1 level of significance. The correlation, as well ils the manner in which items were obtained for the questionnaire, confirms the reliability of the questionnaire. Cronbach’s alpha (8), or the internal consistency of the questionnaire, was alpha = .96 for the first administration and alpha = .97 for the second administration. These results also demonstrate the reliability of the questionnaire, as well as reflecting that the instrument is internally consistent. Although the purpose of the study was to develop and test an activities Questionnaire for adults with asthma, data were provided with respect to the items responded to by the 46 subjects. This information provides an index of the type and level of restriction experienced by the subjects. The data were quantified in the following manner: (a) total restriction = 4; (b) severe restriction = 3; (c) moderate restriction = 2; (d) some restriction == 1; and (e) no restriction = 0. Patients either noted N.IA for not applicable or left items blank that did not apply to them. Mean scores for items in which patients were most restricted are reported in Table 1 for each administration and according to the seven categories of items. The table also depicts the
Creer et al.
396 Table 1
Percentage of Subjects and Their Scores on Selected Items in the Seven Categories on the Life Activities Questionnaire for Adult Asthma FIRST ADMl N ISTRATION
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ITEM
PERCENTAGE
Category I : Physical Activities Climbing stairs Exercising Wa Ik ing Hurrying too much Sexual activities Running/joggi ng Playing with children or grandchildren Category I / : Work Activities Overexertion/fatigue Heavy lifting Working around odorskhemicals Category / / I : Outdoor Activities Walking outside Being around vehicle exhaust fumes Encountering pet animals Shoveling snow Category / V : €motions and €motional Behaviors Laughing Stress Shouting Crying Category V : Home Care Vacuuming Dusting Working around perfumes, etc. Working around odors or smoke Working with household chemicals Category VI: Eating and Drinking Activities Drinking alcoholic beverages Eating foods with MSG Category VII: Miscellaneous Sleeping Being in a smoke-filled environment Taking a hot, steamy shower or bath Speaking Singing Visiting friends with pets
SECOND ADMINISTRATION
SCORE
PERCENTAGE
SCORE
98 96 96 96 89 76 76
.89 1.30 .70 1.27 .66 1.89 .54
98 93 96 93 91 72 76
.87 1.49 .75 1.21 .48 1.97 .48
89 85 80
1.37 1 .oo 1.84
85 78 80
1.38 1.05 1.84
89 85 80 74
1.34 1.77 1.30 1.68
89 80 78 65
1.12 1.32 1.25 .87
91 89 87 83
1.oo 1.34 1.05 .84
93 89 85 83
.71 1.12 1.03 .68
100 93 93 89 87
1.13 1.49 1.51 2.17 1.90
96 98 87 96 91
1 .oo 1.38 1.58 2.02 1.98
80 74
1 .oo .9 1
76 74
.9 7 .85
93 91 89 89 83 78
.8 1 2.67 .49 .5 1 .74 1.53
96 98 93 91 76 76
.6 1 2.51 .47 .38 .83 1.34
percentage of patients who endorsed particular items on the questionnaire. Category I, or physical activities, includes 21 items. Items reported by a majority of subjects as contributing to activity restriction included climbing stairs, exercising, wallung, hurrying too much, sexual activities, running/jogging, and playing with children or grandchildren. Items that caused the greatest
amount of restriction were running/jogging, exercising, and hurrying too much. As depicted in Table 1, these items sometimes resulted in some restriction to moderate restriction. Category I1 includes four work activities. The majority of subjects listed overexertion/ fatigue, heavy lifting, and working around odors or chemicals as restricting their activi-
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Life Activities Questionnaire for Adults ties. Working around chemicals or odors, overexertionifatigue, and heavy lifting led to the highest mean scores of activity restriction, respectively. These items also resulted in some restriction to moderate restriction. Category III contains 12 outdoor activities. Activities cited most by subjects as apt to be restricted by asthma included walking outside (several qualified their answer by saying this mainly occurred in cold weather), being around vehicle exhaust fumes, encountering pet animals, and shoveling snow. The mean level of restriction ranged from some restriction to moderate restriction. The decrease in the mean score for shoveling snow in the second administration of the questionnaire is attributable to the time of the year the questionnaire was administered (early spring), when shoveling snow is less likely to be thought of as a regular activity. This change reflects the sensitivity of the measure in detecting environmental changes that may lead to restriction of activity in patients. Category IV, which includes four items, is a different category than the others; the category includes emotions and emotional behaviors described by patients as interacting with their asthma forcing restricted activity. Emotions or emotional behaviors were reported by a high percentage of all subjects a s contributing to their restriction. Stress interacte'd most with asthma and produced the highest mean level of restriction. Fifteen items regarding home care are included in Category V. As noted in Table 1, items most regarded a s leading to activity restriction were vacuuming; dusting; working around perfumes, incense, and other household odors; working around odors or smoke; and working with household chemicals. Working around odors or smoke was credited with producing the greatest amount of activity restriction, followed by working with hou:sehold chemicals, working with perfumes, incense, and other household odors, dusiing, and vacuuming, respectively. Working around odors or smoke resulted in a mean restriction that fell between moderate and severe restriction. Category VI contains five items related to eating and drinking. The highest percentage of subjects listed drinking alcoholic bever-
397 ages as restricting their activities; a second item was eating foods with MSG. With respect to level of restriction, drinking alcoholic beverages and eating foods with MSG, respectively, were described as producing the greatest amount of restrictron. A number of respondents wrote that they attempted to avoid both alcohol or products with MSG. Avoidance of products with these chemicals likely contributed to the low mean score of restriction credited to either akohol or MSG. The final category of items, Category VII, is concerned with miscellaneous activities reported by patients; eight items are contained in this section. Those activities said to be restricted by asthma included sleeping, being in a smoke-filled environment, taking a hot, steamy bath or shower, speaking, singing, and visiting friends with pets. The two items credited with leading to the greatest levels of restriction were being in a smoke-filled environment and visiting friends with pets. Being in a smoke-filled environment, in fact, registered the highest mean level of restriction of all items. At the conclusion of each category of the questionnaire, several blank spaces were provided to permit patients to add an activity that they thought contributed to restricting their activities. This allowed patients to describe items that resulted in activity restriction which may have been unique to them and not covered by the questionnaire. A number of patients noted various activities, but these were covered in other sections of the questionnaire. Only one item was written in more than once: three respondents reported that premenstrual syndrome (PMS) interacted with their asthma and resulted in activity restriction. Consideri.ng their comments, PMS might be added a s an item according to the purposes for which the instrument is used in the future.
DISC USSlO N We described the development and testing of an activity restriction instrument for use with adults with asthma. In designing Life Activities for Adult Asthma, content validity was achieved by asking 90 patients to identify
Creer et al.
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activities they perceived as being limited, at various times and in varying degrees, by their asthma. The items the 90 individuals reported were included in the subsequent questionnaire, contingent on the fact that the items were reported as causing activity restriction by two or more people. The reliability and internal consistency of the resulting questionnaire was determined with an independent sample of 46 adults with asthma. Internal consistency proved high (alpha = .96 for the first administration and alpha = .97 for the second administration), and the onemonth test-retest reliability was sound (r = .80); thus, the Life Activities Questionnaire for Adult Asthma has solid psychometric properties for use with asthmatic adults. There are two potential uses of the questionnaire. First, the instrument would be useful in determining the extent to which a wide array of activities are perceived as restricted because of asthma. The 5-point rating scale permits changes ranging from no restriction to total restriction to be recorded; the instrument, therefore, is sensitive to changes that occur in patients over time. The sensitivity of the questionnaire would thus be valuable in making clinical, research, or policy-making decisions. A second use of the instrument is as a component in a battery of instruments developed and tested to assess quality of life in adults with asthma. Two approaches have been taken in developing quality of life instruments (4). One approach is to develop a global measure that can be used across diseases or disorders. There is merit to this approach as the impact of asthma on patients, for example, can be compared with the impact that other respiratory disorders have on patients. There are instruments available that provide global assessment, including the Quality of Well-Being Scale (9) and the Sickness Impact Profile (10). The question that arises with these instruments is whether they are applicable to patients with asthma because of the unique characteristics of the disorder (e.g., the intermittent and variable nature of asthma). Research has shown that the Quality of Well-Being Scale is useful with
patients with chronic obstructive pulmonary disease (11);ongoing research is evaluating use of the instrument with asthmatic adults. This should demonstrate whether the Quality of Well-Being Scale is useful in assessing the quality of life experienced by these patients. No one, as yet, has used the Sickness Impact Profile to any extent with asthma. The second approach is to develop a disorderspecific instrument. This tactic has been widely taken with other diseases, particularly cancer (3,4,12). A disadvantage is that global assessment is sacrificed with the approach. This can, in turn, make it difficult to compare the impact of asthma with the influence other diseases or disorders have on patients. The advantage of this approach is that an instrument or, more likely, a battery of instruments can be tailored to fit the unique characteristics of asthma. Ware (2) presented operational definitions of six health concepts that might be included in a battery of instruments designed to measure quality of life: physical functioning, mental health, social well-being, role functioning, general health perceptions, and symptoms. Specific instruments are available to assess most of these functions in adults with asthma. The Life Activities Questionnaire for Adult Asthma should become an integral component of a quality of life battery because it permits clinicians, investigators, or policy makers to determine the impact of asthma on the physical functioning of adults with the disorder.
ACKNOWLEDGMENT The authors thank Jennifer Creer Hatala for her help in collecting and collating the data. A copy of the complete Life Activities Questionnaire for Adult Asthma is available through the authors.
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399 7. SPSS. SPSS-X User's Guide, 3rd ed. Chicago: Author, 1988. 8. Cronbach LJ, Gleser GC, Nanda H, Rajaratnam N. 'The Dependability of Behavioral Measurements. New York, Wiley, 1972. 9. Kaplan RM, Atkins CJ, Timms R. Validity of a Quality of Well-Being Scale as an outcome measure in chronic obstructive pulmonary disease. / Chron Dis 37:85-95, 1984. 10. Bergner M, Bobbitt RA, Carter WB, Gilson BS. The Sickness Impact Profile: Development and final revision of a health status measure. Med Care 19:787805, 1981. 11. Atkins CJ, Kaplan RM, Timms RM, Rinsch S, Loftback K. Behavioral programs for exercise compliance in COPD. / Consult Clin Psycho1 52:591-603, 1984. 12. Falotico-Taylor J, McClellan M, Mosteller F. The use of quality-of-life measures in technology assessment. In Quality of Life and Technology Assessment (Mosteller F, Falotico-Taylor J, editors), Washington, DC,National Academy Press, 1989, pp. 7-43.
