Original Article
Prior Study of Cross-Cultural Validation of McGill Quality-of-Life Questionnaire in Mainland Mandarin Chinese Patients With Cancer
American Journal of Hospice & Palliative Medicine® 2015, Vol. 32(7) 709-714 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909114537400 ajhpm.sagepub.com
Liya Hu, MD1, Jingwen Li, MA1, Xu Wang, PhD2, Sheila Payne, MD3, Yuan Chen, MD1, and Qi Mei, MD1
Abstract The validation of McGill quality-of-life questionnaire (MQOLQ) in mainland China, which had already been used in multicultural palliative care background including Hong Kong and Taiwan, remained unknown. Eligible patients completed the translated Chinese version of McGill questionnaires (MQOL-C), which had been examined before the study. Construct validity was preliminarily assessed through exploratory factor analysis extracting 4 factors that construct a new hypothesis model and then the original model was proved to be better confirmed by confirmatory factor analysis. Internal consistency of all the subscales was within 0.582 to 0.917. Furthermore, test–retest reliability ranged from 0.509 to 0.859, which was determined by Spearman rank correlation coefficient. Face validation and feasibility also confirm the good validity of MQOL-C. The MQOL-C has satisfied validation in mainland Chinese patients with cancer, although cultural difference should be considered while using it. Keywords McGill quality-of-life questionnaire, validation, China, cancer, palliative care, quality of life assessment
Introduction On the setting of the massive number of patients with cancer and cancer’s rising morbidity and mortality, the growing significance of the evaluation on quality of life turns out to be strikingly highlighted.1 The primary purpose of any cancer treatment is to improve the quality of patients’ lives, hopefully by curing the disease but also by ameliorating the worst symptoms for as long period as possible. Nevertheless, when curative treatments no longer work, or are not an option any more, the medical team shifts the focus from prolonging life to optimizing the patients’ quality of life (QOL) at the end of life. With the exploration of its various domains, QOL turns out to be hardly defined because of the wide range of its content rather than just focused on physical symptoms.2,3 Yet, on the basis of Aristotle in Ethica Nicomachea,4 it at least includes individuals’ perceptions of their position in life in the setting of the culture and value orientations in which they live, and in relation to their physical health, psychological state, level of independence, social relations, personal beliefs, and relationship to salient features of the environment. Quality-of-life assessments were laid claim as the most important outcome of palliative care in patients with cancer.5,6 McGill Quality-of-Life Questionnaire (MQOLQ) was first designed in 1975 to measure quality of life of people at all stages of a life-threatening illness, from diagnosis to cure or
death.7 The instrument was carefully created to overcome some of the shortcomings of traditional measures used to assess patients with life-threatening illnesses.8 It turns out to be one of the tools with the strongest psychometric properties.9 The MQOLQ assesses general domains applicable to all patients, incorporates the existential domain, balances physical and nonphysical aspects of quality of life, and includes both positive and negative influences to avoid implicit response bias on quality of life.10 The subscales could be presented in 4 domains (physical, psychological, existential, and support).11 It is a patient-reported instrument that employs 16 items plus a single-item global scale. Every item takes shape in a 10-point scale to measure the degree of subjective feeling.
1
Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China 2 Faculty of Health & Social Sciences, Psychology, Leeds Metropolitan University, Leeds, United Kingdom 3 Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom Corresponding Author: Qi Mei, MD, Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue 1095, 430030 Wuhan, China. Email: [email protected]
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710 First published in 1975, the MQOLQ was developed and validated in Canada for life-threatening diseases, especially for the palliative care patients.12 The MQOLQ has been translated into different languages, such as Spanish, French, Korean, and Hebrew, and has been widely used in palliative care studies among patients with cancer in various countries.13-16 In a previous study, MQOLQ was also translated into Chinese and achieved grateful validation in Hong Kong17 and Taiwan.18 Moreover, the Hong Kong version of MQOL (MQOL-HK) had been modified by adding 3 additional items (face, eating, and sex).17 Although Taiwan, Hong Kong, and mainland China largely originate from similar cultures and shared ancestry, their styles of culture have been greatly influenced by their different sociopolitical systems.19 Additionally, the reform and opening up policy in China implemented only for nearly 40 years comparing with Hong Kong and Taiwan who had been influenced by the Western cultures for more than 100 years. Still the sex topic seemed to be much more sensitive than the westerners. The age of the onset of tumor concentrates in the population of 40 to 60 years old who were deeply influenced by traditional Chinese culture. Concerning the difference in culture, whether MQOLQ could be used in Mandarin Chinese patients with cancer is still a question, which raises the purpose of our study.
employed with regard to age, performance status, or stage of disease. To avoid implicit response bias, specially trained investigators explained the purpose of the study. All the research was carried out by the patients themselves. If needed, questions could be read aloud by the trained investigators to patients, mainly for the elderly and the illiterate or semiliterate individuals. During their stay in hospital, patients were required to fill out the complete inventory of MQOL-C, and in cases where the questionnaires are filled by or with the aid of other people instead of the research assistants, the authenticity and objectivity of the scale are ensured. At the same time, we collected the information of patient’s gender, age, disease types, and tumor stage from the patient’s doctors. Performance status was measured by the Karnofsky performance status (KPS) scores and reassured by their doctors at the time of investigation. In their first assessments, participants were provided with consent forms, whose voluntarily behavior of turning over the questionnaire demonstrated the will to participate in the study. All scales were completed within 7 days after admission into the hospital. If consented, appointments were made for a second assessment on a 7-day interval. The cancer center ethics committee’s approval in Tongji Hospital was granted for the survey.
Feasibility and Demographic Analysis
Methods Translation of the Original MQOLQ into Chinese In light of cultural discrepancy between China and Western countries, Chinese act out more sensitive or conservative to the topic of sex, different from Hong Kong or Taiwanese affected by the Western culture for more than 1 century. So under the consent of Cohen, while avoiding the bias of the response rate when in the face of sensitive topic, we decided to translate the original MQOLQ into Chinese, rather than impertinently using MQOL-HK. The translation was carried out by 4 independent translators and 2 oncologists. Two independent translators, who spoke English as native language and worked in Tongji Medical College, following a consensus meeting with the oncologists (worked in Tongji Hospital), translated the MQOL into Chinese (MQOL-C). The other 2 independent translators, who had little known about the MQOLQ, again performed the back translation into English. Three other comparers whose major were English compared the 2 version of the scale by rating the grade of similarity.
Patients’ Selection and Scales’ Acquisition Continuous admitted patients were recruited from Tongji Hospital and the 11th People’s Hospital in Wuhan, China, for 6 months. Suitable patients are defined as (1) diagnosed with cancer, (2) have basic understanding in Chinese, which can be judged by whether they could reach efficient communication with the investigators, (3) general physical condition could meet the demand of an oral or written survey at least, and (4) informed consent provided. No more restrictions were
Feasibility was laid out by the percentage of missing responses, and the completion time and the demographic analysis were revealed not only in both the first and second time reliability tests but also in the validation analysis.
Validation Analysis Face validation. Logical and statistical analyses were coalesced to evaluate face validity. Three comparers rated the similarity by 3 degrees (‘‘different’’,‘‘similar’’, and ‘‘exact’’) on each item between the original English version and the back-translation scale before the research. Besides, the correlation coefficient between every single item score and total score was analyzed to obtain the effectively relevant significance. The score of 9 to 16 items, which were disjunctive questions, had been reserved before calculating the correlation coefficient. Construct validation. We randomly divided the participants into 2 groups, which were used to appraise the construct validity through exploratory factor analysis (EFA) in 1 group to extract common factors and subsequently to inspect the credibility of the scale model through confirmatory factor analysis (CFA) by aid of the SPSS 17.0 (SPSS, Chicago, IL, USA) and Amos 20 (IBM, Chicago, IL, USA) software. Exploratory factor analysis can explain the potential structure on the basis of the correlation between variables. In fact, however, measurement error of each time is not consistent, which would affect the correlation coefficient and influence the accuracy of the interpretation on potential structure. Thus combining with CFA, whether different hypothesis model is reasonable could be verified.20
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Table 1. Baseline Characteristics of MQOL-C. Baseline characteristics Age, years old Maximum, minimum Mean (SD) Gender, % Male Female Cancer etiology, % Thoracic cancer Digestive cancer Head and neck cancer Genitourinary cancer Other cancers Tumor stage, % Stage I Stage II Stage III Stage IV Undiagnosed
All participants (n ¼ 126)
EFA (n ¼ 63)
CFA (n ¼ 63)
Test–retest (n ¼ 84)
84, 20 48.9 (15.8)
84, 22 44.4 (12.8)
79, 20 47.9 (16.0)
20, 69 42.8 (17.2)
55.6 44.4
52.1 47.9
55.8 44.2
42.9 57.1
41.3 25.4 7.9 17.5 7.9
48.2 23.8 8.1 13.8 6.1
44.1 22.5 7.0 19.2 7.2
42.0 15.8 10.8 16.3 15.1
4.8 19.5 24.3 39.7 11.7
5.4 18.2 22.6 40.9 12.9
6.7 11.5 26.3 44.7 10.8
9.4 22.9 38.2 24.1 5.4
Abbreviations: CFA, confirmatory factor analysis; EFA, exploratory factor analysis; MQOL-C, Chinese version of McGill quality-of-life questionnaire; SD, standard deviation.
Reliability Analysis Internal consistency reliability. Through the measurement of Cronbach a values of each subscale together with the total score of the MQOL-C, the internal consistency reliability was determined using the scale data of all participants. Test–retest reliability. Test–retest reliability was done with the same patients (all participants) in a second investigation and was analyzed by means of correlation analysis. After 7 days, before the patients started their second investigation, they will answer a ‘‘condition changing question,’’ judging whether their condition had changed compared to a week before. They were given 3 degrees to choose (a lot, a little, and little). Participants whose condition had little changed 7 days later together with their KPS scores change within plus or minus 2-point range were chosen to be interviewed a second time. Test–retest reliability was tested though calculating Spearman rank correlation coefficient (rs).
with the median age of around 48. In all participants, half of the patients were between 40 and 60 years old. The ratio of men and women is close to 1:1. Other rare tumors were classified as ‘‘other cancers.’’ In the staging of cancer, almost 40% of the patients are in stage IV, and only 1 to 10 are in stage I. No significant differences were found from the demographic data between every patient group so as to ensure the statistical consistency of the population and comparability of data. In 138 (completion rate ¼ 91.3%) qualified scales, 126 were collected from the oncology unit in Tongji Hospital (n ¼ 90) and the 11th People’s Hospital (n ¼ 36) in Wuhan in the duration of 6 months, with the completion time of 10.5 minutes (standard deviation ¼ 1.8, range ¼ 2.4-11.9 minutes). Twelve (8.7%) participants’ scales were incomplete thus excluded from the analyzable sample. In the matter of test–retest reliability, the completion rate is 87.5% (n ¼ 84) in which 90 patients stayed in the same condition.
Validity Analysis Results After 6 months of selection in 2013, 138 patients (suitable sample), which could all meet the above-mentioned criteria, provided the written consent. Finally, 126 qualified MQOL-C scales (analyzable sample) turned in for the first time. Of the 90 patients whose condition remained stable, 84 finished the test and retest reliability analysis 7 days later.
Demographic and Feasibility Results As we can see from Table 1, in the age distribution of sample, the minimum age is only 20 years, and the eldest is as old as 84,
Face validity. All the items were all scored with ‘‘exact’’ except for item 12 (Life control) with only similar from 1 in 3 comparers. The coincidence rate was as high as 93.75%. Statistical correlations could be draw from each item with total score of the scale and the total score of each dimension, besides item 1 (physical well-being) laid the highest correlation with the psychological dimension (Table 2). Overall, we could see the satisfied face validity of the scale. Construct validity. Principal component analysis result shows Kaiser-Meyer-Olkin ¼ 0.655, with Bartlett test statistic X ¼ 464.819, P ¼ .000, which manifested no big
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712 Table 2. Correlations between each items and corresponding domains.
MQOL-C domains MQOL-C items Global Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item 10 Item 11 Item 12 Item 13 Item 14 Item 15 Item 16
Global (sig.)
Physical (sig.)
Psychological (sig.)
Existential (sig.)
Support (sig.)
1.000 0.321** 0.257* 0.231** 0.386** 0.375** 0.297* 0.373** 0.829** 0.297** 0.174 0.129** 0.329* 0.265* 0.235 0.443 0.535
0.033 0.022 0.810**(.000) 0.902**(.000) 0.826**(.000) 0.153 0.121 0.163 0.110 0.255* 0.287* 0.200 0.150 0.118 0.148 0.137 0.108
0.439*(.023) 0.196 0.126 0.222 0.026 0.895**(.000) 0.871**(.000) 0.947**(.009) 0.873**(.007) 0.255* 0.282* 0.252* 0.122 0.102 0.186 0.086 0.024
0.563* 0.479** 0.309* 0.190 0.105 0.154 0.116 0.271* 0.327** 0.858**(.006) 0.591** 0.942**(.009) 0.919**(.004) 0.955**(.007) 0.691** 0.674** 0.554**
0.239** 0.347** 0.100 0.094 0.164 0.097 0.014 0.126 0.137* 0.572** 0.938**(.000) 0.664** 0.591** 0.662** 0.936**(.000) 0.935**(.000) 0.892**(.000)
Spearman’s rank coefficiency (rs). *Significant at p < 0.05. **Significant at p < 0.01.
Table 3. Factors Loading for the MQOL-C Items. MQOL-C items
Support Existential Psychological Physical
Physical symptom 1 0.121 Physical symptom 2 0.048 Physical symptom 3 0.175 Physical well-being 0.118 Depressed 0.067 Anxious 0.015 Sad 0.000 Fear of future 0.038 Personal existence 0.327 Achieving life goals 0.226 Life . . . worthwhile 0.422 Life control 0.284 Feel good about myself 0.388 Closeness 0.873 Every day seems a gift 0.652 World is caring 0.827
0.366 0.078 0.070 0.048 0.067 0.046 0.113 0.230 0.753 0.696 0.599 0.680 0.541 0.327 0.345 0.226
Table 4. Confirmatory Factor Analysis Results on the Original and New Model of MQOLQ. Model
0.084 0.123 0.020 0.601 0.800 0.791 0.597 0.660 0.162 0.182 0.177 0.075 0.016 0.044 0.138 0.068
0.732 0.879 0.848 0.188 0.064 0.022 0.075 0.092 0.141 0.153 0.066 0.042 0.055 0.011 0.093 0.060
Abbreviation: MQOL-C, Chinese version of McGill quality-of-life questionnaire.
differences between the variables. Hence, the data were suitable for EFA. After factors analysis, 4 factors (eigenvalues > 1.0) were extracted, which contained 16 items and accounted for 85.416% variance. After rotating the 4 factors, factor loadings laid between 0.541 and 0.879 (Table 3). According to the clinic practice, the second to fourth questions represented physical domain. At the same time, physical well-being, depressed, anxious, sad, and fear of future accounted for psychological domain. The existential domain incorporated 5 items, which were personal existence, achieving life goals, feel good about oneself, life . . . worthwhile,
M0 M1
X2
GFI
AGFI
RMSEA
NFI
CFI
TLI
IFI
410.90 390.30
0.73 0.69
0.65 0.59
0.19 0.12
0.79 0.80
0.83 0.79
0.80 0.63
0.79 0.70
Abbreviations: AGFI, adjusted goodness of fit index; CFI, comparative fit index; GFI, goodness of fit index; IFI, incremental fit index; MQOLQ, McGill qualityof-life questionnaire; NFI, normed fit index; RMSEA, root mean square error of approximation; TLI, Tucker-Lewis index.
and life control, while the remaining 3 items fell in the support domain. The results are basically identical with the original English version, except for item 14 (every day seems a gift), which should belong to existential domain with more factor loading in the support domain. In correlation coefficient, it had approximate equal result in 2 dimensions as shown in Table 2. The question on which dimension should item 14 precisely explains deserved further exploration. According to the semblable correlation within the 2 domains, whether item 14 should be placed in the support rather than the existential domain remained undecided. We tried to set up a new 4-dimensional scale model according to the factor analysis result through EFA and then compared it with the original model. M1 model was established based on the new 4 dimensions with item 14 classified into support domain, whereas M0 model represented the original one, in which item 14 belonged to existential domain. The results were listed in Table 4. From the results, we could conclude that the M0 model was more satisfied than M1. We reached the decision that every day seems a gift should be placed in the
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Table 5. Internal Consistency and the Test–Retest Results of the MQOL-C and Its Subscales.
Global QOL item Physical subscale Psychological subscale Existential subscale Support subscale
Test 1 (n ¼ 126)
Test 2 (n ¼ 84)
Cronbach a
Spearman rs Cronbach a
0.689 0.615 0.917 0.768 0.912
0.549a 0.554a 0.509a 0.784a 0.859a
0.632 0.793 0.827 0.778
Abbreviations: MQOL-C, Chinese version of McGill quality-of-life questionnaire. a Significant at P < .01.
existential dimension, which still confirmed the original 4dimensional scale of the English version.
Reliability Analysis Internal consistency reliability. All internal consistency scores of the subscales for the first survey (test 1) and the second time survey (test 2) were within the recommended range (0.70), which ranged from 0.68 to 0.92, except that the physical scale was only 0.582 and 0.632, respectively, in the moderate level for the first and second tests (Table 5). Test–retest reliability. Although calculating Spearman rs, Global QOL item, physical, and existential domain had moderate reliability results (0.509-0.554), while psychological and support domains had better reliability result (0.784 and 0.859, respectively; Table 5).
Conclusions From the demographic information, we can clearly see that the age distribution of patients with cancer is wide, with diverse disease types and late stage when diagnosed. This requires that more attention should be paid to the treatment of cancer and to the patients with cancer, especially at terminal stage, which attaches great importance to quality of life and end-of-life care. Under the condition of consistent demographic data distribution, reliability and validity of MQOL-C were verified in this prior study in Mandarin Chinese patients with cancer. Face validity showed that each items mostly related to their corresponding subscale scores, other than physical well-being, which represented the symptom burden of patients with cancer. Identically we can also see the phenomenon in factor analysis, factor loading of physical well-being in the physical domain was small at 0.188, whereas the psychological domain was high at 0.335. Symptom burden may nevertheless be distressing, if persistent, unrelieved, or ignored.21 Physical well-being, which was manifested in cachexia symptoms like pain, vomiting, insomnia, and fatigue in our survey, may affect the psychological status of the patients as well.22 Similarly, in the Korea15 version, factor loading of this item reached only 0.00 in the physical domain and, as in the present study, high factor loadings existed
in the psychological domain. In the validation in Hebrew,16 Physical well-being had high factor loadings in the physical and existential domains. This point reflected the heterogeneity within the cross-cultural application of scale, thus further strengthen the necessity of the cross-cultural validation test. In factor analysis, the result was basically consistent with the original English version, yet excluded the item 14 (every day seems a gift). Even cooperate with the correlation result, whether it interpreted the existential or the support domain stayed a critical problem. With further verification by means of CFA, original scale model is still slightly better than the new model, which concluded that the item 14 belongs to the support domain. We could infer from another perspective that maybe every day seems a gift could not just or fully explain only 1 dimension under the background of Chinese culture. Combined with religion differences, China’s religious faith (such as Buddhism) is far less prevalent than abroad (Christianity and Islam). And many people who had religious faith more concentrated among the minorities resided in Western region and rural areas,23 whereas the participants in our study mostly came from central region. So for people in this study, gift can be understood as the gratitude toward their families’ support or be interpreted as a negative emotion due to the self-exist burden they brought to the people around, rather than the strong feeling of the existence for another day, which belongs to the ‘‘god’s’’ gift. Annotation from the cultural level, China has more higher collectivism attitude compared to Western countries, which emphasize more in individualism.24 Feeling supported by the surroundings relates more with the collectivism than personal existence. Similar results could be seen from Japanese version of MQOL (MQOL-J) and Taiwan version in which item 14 loaded more in support domain. However in MQOL-HK, it still had the highest factor loading in psychological domain. Thus, we could see the culture and religion difference between those studies. For the feasibility study, patients could complete MQOL-C in less than 20 minutes and completed it on their own without seeking much help. Meanwhile, the correlation of psychological and support dimension with total score of the scales appeared most close. Conclusions could be drawn that the instrument was designed to be general in nature in order to maintain brevity and to assure applicability to all patients, which strongly supported its wide use. The internal consistency reliability also gets good results through Cronbach a value. In all QOL domains,3 out of 4 reach the recommending standard (>0.7) except the physical domain. Identically, test–retest reliability belongs to the stable coefficient. The aims at the validation of a scale laid more than the application under multicultural circumstances, but more vitally in the routine use for assessing internationally in specific aspects of quality of life. Thus, a tool for international comparison in clinical research was not only utilized in developed countries but also assessed in developing countries like Iran25 and Korean.15 So for patients experiencing with cancer, especially in China which is a developing country with a huge population base and increasing incidence of cancer, quality of their lives in palliative care setting becomes a burning problem, which is worthy of urgent attention.
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714 In comparison with previous studies on MQOL, no matter MQOL-HK,17 the Taiwan MQOL,16 or the MQOL-J study,26 the reliability and validity results are very similar with our study. Although MQOLQ is one of the most appropriate measures to evaluate the QOL, none of these measures score perfectly on all psychometric criteria, and their multifaith appropriateness requires further testing9 Through this prior validation study of MQOLQ, we hopefully provides a considerable, comprehensive tool for assessing quality of life among mainland Chinese patients with cancer. Further studies were needed for a large sample and multicenter study to test the convergent and divergent validity and the measurement sensitivity for the specific populations. Sex and face, which were part of the MQOL-HK, were not included in our scale on the consideration of bias. More research would be done to investigate these 2 items’ impact on QOL through a more scientific method.
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Acknowledgments The authors are much grateful for Prof C. Yuan and Prof Sheila Payne the productive discussion and valuable editorial improvement in this article. We would like to thank Dr Robin Cohen and her team for agreeing our translation of the MQOL for our study. We appreciate the industrious work from all the staff. Above all, we express our gratitude to all the patients for the participation in the research. This study could not be smoothly conducted without their contribution.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Prior Study of Cross-Cultural Validation of McGill Quality-of-Life Questionnaire in Mainland Mandarin Chinese Patients With Cancer
American Journal of Hospice & Palliative Medicine® 2015, Vol. 32(7) 709-714 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909114537400 ajhpm.sagepub.com
Liya Hu, MD1, Jingwen Li, MA1, Xu Wang, PhD2, Sheila Payne, MD3, Yuan Chen, MD1, and Qi Mei, MD1
Abstract The validation of McGill quality-of-life questionnaire (MQOLQ) in mainland China, which had already been used in multicultural palliative care background including Hong Kong and Taiwan, remained unknown. Eligible patients completed the translated Chinese version of McGill questionnaires (MQOL-C), which had been examined before the study. Construct validity was preliminarily assessed through exploratory factor analysis extracting 4 factors that construct a new hypothesis model and then the original model was proved to be better confirmed by confirmatory factor analysis. Internal consistency of all the subscales was within 0.582 to 0.917. Furthermore, test–retest reliability ranged from 0.509 to 0.859, which was determined by Spearman rank correlation coefficient. Face validation and feasibility also confirm the good validity of MQOL-C. The MQOL-C has satisfied validation in mainland Chinese patients with cancer, although cultural difference should be considered while using it. Keywords McGill quality-of-life questionnaire, validation, China, cancer, palliative care, quality of life assessment
Introduction On the setting of the massive number of patients with cancer and cancer’s rising morbidity and mortality, the growing significance of the evaluation on quality of life turns out to be strikingly highlighted.1 The primary purpose of any cancer treatment is to improve the quality of patients’ lives, hopefully by curing the disease but also by ameliorating the worst symptoms for as long period as possible. Nevertheless, when curative treatments no longer work, or are not an option any more, the medical team shifts the focus from prolonging life to optimizing the patients’ quality of life (QOL) at the end of life. With the exploration of its various domains, QOL turns out to be hardly defined because of the wide range of its content rather than just focused on physical symptoms.2,3 Yet, on the basis of Aristotle in Ethica Nicomachea,4 it at least includes individuals’ perceptions of their position in life in the setting of the culture and value orientations in which they live, and in relation to their physical health, psychological state, level of independence, social relations, personal beliefs, and relationship to salient features of the environment. Quality-of-life assessments were laid claim as the most important outcome of palliative care in patients with cancer.5,6 McGill Quality-of-Life Questionnaire (MQOLQ) was first designed in 1975 to measure quality of life of people at all stages of a life-threatening illness, from diagnosis to cure or
death.7 The instrument was carefully created to overcome some of the shortcomings of traditional measures used to assess patients with life-threatening illnesses.8 It turns out to be one of the tools with the strongest psychometric properties.9 The MQOLQ assesses general domains applicable to all patients, incorporates the existential domain, balances physical and nonphysical aspects of quality of life, and includes both positive and negative influences to avoid implicit response bias on quality of life.10 The subscales could be presented in 4 domains (physical, psychological, existential, and support).11 It is a patient-reported instrument that employs 16 items plus a single-item global scale. Every item takes shape in a 10-point scale to measure the degree of subjective feeling.
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Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China 2 Faculty of Health & Social Sciences, Psychology, Leeds Metropolitan University, Leeds, United Kingdom 3 Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom Corresponding Author: Qi Mei, MD, Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue 1095, 430030 Wuhan, China. Email: [email protected]
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710 First published in 1975, the MQOLQ was developed and validated in Canada for life-threatening diseases, especially for the palliative care patients.12 The MQOLQ has been translated into different languages, such as Spanish, French, Korean, and Hebrew, and has been widely used in palliative care studies among patients with cancer in various countries.13-16 In a previous study, MQOLQ was also translated into Chinese and achieved grateful validation in Hong Kong17 and Taiwan.18 Moreover, the Hong Kong version of MQOL (MQOL-HK) had been modified by adding 3 additional items (face, eating, and sex).17 Although Taiwan, Hong Kong, and mainland China largely originate from similar cultures and shared ancestry, their styles of culture have been greatly influenced by their different sociopolitical systems.19 Additionally, the reform and opening up policy in China implemented only for nearly 40 years comparing with Hong Kong and Taiwan who had been influenced by the Western cultures for more than 100 years. Still the sex topic seemed to be much more sensitive than the westerners. The age of the onset of tumor concentrates in the population of 40 to 60 years old who were deeply influenced by traditional Chinese culture. Concerning the difference in culture, whether MQOLQ could be used in Mandarin Chinese patients with cancer is still a question, which raises the purpose of our study.
employed with regard to age, performance status, or stage of disease. To avoid implicit response bias, specially trained investigators explained the purpose of the study. All the research was carried out by the patients themselves. If needed, questions could be read aloud by the trained investigators to patients, mainly for the elderly and the illiterate or semiliterate individuals. During their stay in hospital, patients were required to fill out the complete inventory of MQOL-C, and in cases where the questionnaires are filled by or with the aid of other people instead of the research assistants, the authenticity and objectivity of the scale are ensured. At the same time, we collected the information of patient’s gender, age, disease types, and tumor stage from the patient’s doctors. Performance status was measured by the Karnofsky performance status (KPS) scores and reassured by their doctors at the time of investigation. In their first assessments, participants were provided with consent forms, whose voluntarily behavior of turning over the questionnaire demonstrated the will to participate in the study. All scales were completed within 7 days after admission into the hospital. If consented, appointments were made for a second assessment on a 7-day interval. The cancer center ethics committee’s approval in Tongji Hospital was granted for the survey.
Feasibility and Demographic Analysis
Methods Translation of the Original MQOLQ into Chinese In light of cultural discrepancy between China and Western countries, Chinese act out more sensitive or conservative to the topic of sex, different from Hong Kong or Taiwanese affected by the Western culture for more than 1 century. So under the consent of Cohen, while avoiding the bias of the response rate when in the face of sensitive topic, we decided to translate the original MQOLQ into Chinese, rather than impertinently using MQOL-HK. The translation was carried out by 4 independent translators and 2 oncologists. Two independent translators, who spoke English as native language and worked in Tongji Medical College, following a consensus meeting with the oncologists (worked in Tongji Hospital), translated the MQOL into Chinese (MQOL-C). The other 2 independent translators, who had little known about the MQOLQ, again performed the back translation into English. Three other comparers whose major were English compared the 2 version of the scale by rating the grade of similarity.
Patients’ Selection and Scales’ Acquisition Continuous admitted patients were recruited from Tongji Hospital and the 11th People’s Hospital in Wuhan, China, for 6 months. Suitable patients are defined as (1) diagnosed with cancer, (2) have basic understanding in Chinese, which can be judged by whether they could reach efficient communication with the investigators, (3) general physical condition could meet the demand of an oral or written survey at least, and (4) informed consent provided. No more restrictions were
Feasibility was laid out by the percentage of missing responses, and the completion time and the demographic analysis were revealed not only in both the first and second time reliability tests but also in the validation analysis.
Validation Analysis Face validation. Logical and statistical analyses were coalesced to evaluate face validity. Three comparers rated the similarity by 3 degrees (‘‘different’’,‘‘similar’’, and ‘‘exact’’) on each item between the original English version and the back-translation scale before the research. Besides, the correlation coefficient between every single item score and total score was analyzed to obtain the effectively relevant significance. The score of 9 to 16 items, which were disjunctive questions, had been reserved before calculating the correlation coefficient. Construct validation. We randomly divided the participants into 2 groups, which were used to appraise the construct validity through exploratory factor analysis (EFA) in 1 group to extract common factors and subsequently to inspect the credibility of the scale model through confirmatory factor analysis (CFA) by aid of the SPSS 17.0 (SPSS, Chicago, IL, USA) and Amos 20 (IBM, Chicago, IL, USA) software. Exploratory factor analysis can explain the potential structure on the basis of the correlation between variables. In fact, however, measurement error of each time is not consistent, which would affect the correlation coefficient and influence the accuracy of the interpretation on potential structure. Thus combining with CFA, whether different hypothesis model is reasonable could be verified.20
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Table 1. Baseline Characteristics of MQOL-C. Baseline characteristics Age, years old Maximum, minimum Mean (SD) Gender, % Male Female Cancer etiology, % Thoracic cancer Digestive cancer Head and neck cancer Genitourinary cancer Other cancers Tumor stage, % Stage I Stage II Stage III Stage IV Undiagnosed
All participants (n ¼ 126)
EFA (n ¼ 63)
CFA (n ¼ 63)
Test–retest (n ¼ 84)
84, 20 48.9 (15.8)
84, 22 44.4 (12.8)
79, 20 47.9 (16.0)
20, 69 42.8 (17.2)
55.6 44.4
52.1 47.9
55.8 44.2
42.9 57.1
41.3 25.4 7.9 17.5 7.9
48.2 23.8 8.1 13.8 6.1
44.1 22.5 7.0 19.2 7.2
42.0 15.8 10.8 16.3 15.1
4.8 19.5 24.3 39.7 11.7
5.4 18.2 22.6 40.9 12.9
6.7 11.5 26.3 44.7 10.8
9.4 22.9 38.2 24.1 5.4
Abbreviations: CFA, confirmatory factor analysis; EFA, exploratory factor analysis; MQOL-C, Chinese version of McGill quality-of-life questionnaire; SD, standard deviation.
Reliability Analysis Internal consistency reliability. Through the measurement of Cronbach a values of each subscale together with the total score of the MQOL-C, the internal consistency reliability was determined using the scale data of all participants. Test–retest reliability. Test–retest reliability was done with the same patients (all participants) in a second investigation and was analyzed by means of correlation analysis. After 7 days, before the patients started their second investigation, they will answer a ‘‘condition changing question,’’ judging whether their condition had changed compared to a week before. They were given 3 degrees to choose (a lot, a little, and little). Participants whose condition had little changed 7 days later together with their KPS scores change within plus or minus 2-point range were chosen to be interviewed a second time. Test–retest reliability was tested though calculating Spearman rank correlation coefficient (rs).
with the median age of around 48. In all participants, half of the patients were between 40 and 60 years old. The ratio of men and women is close to 1:1. Other rare tumors were classified as ‘‘other cancers.’’ In the staging of cancer, almost 40% of the patients are in stage IV, and only 1 to 10 are in stage I. No significant differences were found from the demographic data between every patient group so as to ensure the statistical consistency of the population and comparability of data. In 138 (completion rate ¼ 91.3%) qualified scales, 126 were collected from the oncology unit in Tongji Hospital (n ¼ 90) and the 11th People’s Hospital (n ¼ 36) in Wuhan in the duration of 6 months, with the completion time of 10.5 minutes (standard deviation ¼ 1.8, range ¼ 2.4-11.9 minutes). Twelve (8.7%) participants’ scales were incomplete thus excluded from the analyzable sample. In the matter of test–retest reliability, the completion rate is 87.5% (n ¼ 84) in which 90 patients stayed in the same condition.
Validity Analysis Results After 6 months of selection in 2013, 138 patients (suitable sample), which could all meet the above-mentioned criteria, provided the written consent. Finally, 126 qualified MQOL-C scales (analyzable sample) turned in for the first time. Of the 90 patients whose condition remained stable, 84 finished the test and retest reliability analysis 7 days later.
Demographic and Feasibility Results As we can see from Table 1, in the age distribution of sample, the minimum age is only 20 years, and the eldest is as old as 84,
Face validity. All the items were all scored with ‘‘exact’’ except for item 12 (Life control) with only similar from 1 in 3 comparers. The coincidence rate was as high as 93.75%. Statistical correlations could be draw from each item with total score of the scale and the total score of each dimension, besides item 1 (physical well-being) laid the highest correlation with the psychological dimension (Table 2). Overall, we could see the satisfied face validity of the scale. Construct validity. Principal component analysis result shows Kaiser-Meyer-Olkin ¼ 0.655, with Bartlett test statistic X ¼ 464.819, P ¼ .000, which manifested no big
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712 Table 2. Correlations between each items and corresponding domains.
MQOL-C domains MQOL-C items Global Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item 10 Item 11 Item 12 Item 13 Item 14 Item 15 Item 16
Global (sig.)
Physical (sig.)
Psychological (sig.)
Existential (sig.)
Support (sig.)
1.000 0.321** 0.257* 0.231** 0.386** 0.375** 0.297* 0.373** 0.829** 0.297** 0.174 0.129** 0.329* 0.265* 0.235 0.443 0.535
0.033 0.022 0.810**(.000) 0.902**(.000) 0.826**(.000) 0.153 0.121 0.163 0.110 0.255* 0.287* 0.200 0.150 0.118 0.148 0.137 0.108
0.439*(.023) 0.196 0.126 0.222 0.026 0.895**(.000) 0.871**(.000) 0.947**(.009) 0.873**(.007) 0.255* 0.282* 0.252* 0.122 0.102 0.186 0.086 0.024
0.563* 0.479** 0.309* 0.190 0.105 0.154 0.116 0.271* 0.327** 0.858**(.006) 0.591** 0.942**(.009) 0.919**(.004) 0.955**(.007) 0.691** 0.674** 0.554**
0.239** 0.347** 0.100 0.094 0.164 0.097 0.014 0.126 0.137* 0.572** 0.938**(.000) 0.664** 0.591** 0.662** 0.936**(.000) 0.935**(.000) 0.892**(.000)
Spearman’s rank coefficiency (rs). *Significant at p < 0.05. **Significant at p < 0.01.
Table 3. Factors Loading for the MQOL-C Items. MQOL-C items
Support Existential Psychological Physical
Physical symptom 1 0.121 Physical symptom 2 0.048 Physical symptom 3 0.175 Physical well-being 0.118 Depressed 0.067 Anxious 0.015 Sad 0.000 Fear of future 0.038 Personal existence 0.327 Achieving life goals 0.226 Life . . . worthwhile 0.422 Life control 0.284 Feel good about myself 0.388 Closeness 0.873 Every day seems a gift 0.652 World is caring 0.827
0.366 0.078 0.070 0.048 0.067 0.046 0.113 0.230 0.753 0.696 0.599 0.680 0.541 0.327 0.345 0.226
Table 4. Confirmatory Factor Analysis Results on the Original and New Model of MQOLQ. Model
0.084 0.123 0.020 0.601 0.800 0.791 0.597 0.660 0.162 0.182 0.177 0.075 0.016 0.044 0.138 0.068
0.732 0.879 0.848 0.188 0.064 0.022 0.075 0.092 0.141 0.153 0.066 0.042 0.055 0.011 0.093 0.060
Abbreviation: MQOL-C, Chinese version of McGill quality-of-life questionnaire.
differences between the variables. Hence, the data were suitable for EFA. After factors analysis, 4 factors (eigenvalues > 1.0) were extracted, which contained 16 items and accounted for 85.416% variance. After rotating the 4 factors, factor loadings laid between 0.541 and 0.879 (Table 3). According to the clinic practice, the second to fourth questions represented physical domain. At the same time, physical well-being, depressed, anxious, sad, and fear of future accounted for psychological domain. The existential domain incorporated 5 items, which were personal existence, achieving life goals, feel good about oneself, life . . . worthwhile,
M0 M1
X2
GFI
AGFI
RMSEA
NFI
CFI
TLI
IFI
410.90 390.30
0.73 0.69
0.65 0.59
0.19 0.12
0.79 0.80
0.83 0.79
0.80 0.63
0.79 0.70
Abbreviations: AGFI, adjusted goodness of fit index; CFI, comparative fit index; GFI, goodness of fit index; IFI, incremental fit index; MQOLQ, McGill qualityof-life questionnaire; NFI, normed fit index; RMSEA, root mean square error of approximation; TLI, Tucker-Lewis index.
and life control, while the remaining 3 items fell in the support domain. The results are basically identical with the original English version, except for item 14 (every day seems a gift), which should belong to existential domain with more factor loading in the support domain. In correlation coefficient, it had approximate equal result in 2 dimensions as shown in Table 2. The question on which dimension should item 14 precisely explains deserved further exploration. According to the semblable correlation within the 2 domains, whether item 14 should be placed in the support rather than the existential domain remained undecided. We tried to set up a new 4-dimensional scale model according to the factor analysis result through EFA and then compared it with the original model. M1 model was established based on the new 4 dimensions with item 14 classified into support domain, whereas M0 model represented the original one, in which item 14 belonged to existential domain. The results were listed in Table 4. From the results, we could conclude that the M0 model was more satisfied than M1. We reached the decision that every day seems a gift should be placed in the
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Table 5. Internal Consistency and the Test–Retest Results of the MQOL-C and Its Subscales.
Global QOL item Physical subscale Psychological subscale Existential subscale Support subscale
Test 1 (n ¼ 126)
Test 2 (n ¼ 84)
Cronbach a
Spearman rs Cronbach a
0.689 0.615 0.917 0.768 0.912
0.549a 0.554a 0.509a 0.784a 0.859a
0.632 0.793 0.827 0.778
Abbreviations: MQOL-C, Chinese version of McGill quality-of-life questionnaire. a Significant at P < .01.
existential dimension, which still confirmed the original 4dimensional scale of the English version.
Reliability Analysis Internal consistency reliability. All internal consistency scores of the subscales for the first survey (test 1) and the second time survey (test 2) were within the recommended range (0.70), which ranged from 0.68 to 0.92, except that the physical scale was only 0.582 and 0.632, respectively, in the moderate level for the first and second tests (Table 5). Test–retest reliability. Although calculating Spearman rs, Global QOL item, physical, and existential domain had moderate reliability results (0.509-0.554), while psychological and support domains had better reliability result (0.784 and 0.859, respectively; Table 5).
Conclusions From the demographic information, we can clearly see that the age distribution of patients with cancer is wide, with diverse disease types and late stage when diagnosed. This requires that more attention should be paid to the treatment of cancer and to the patients with cancer, especially at terminal stage, which attaches great importance to quality of life and end-of-life care. Under the condition of consistent demographic data distribution, reliability and validity of MQOL-C were verified in this prior study in Mandarin Chinese patients with cancer. Face validity showed that each items mostly related to their corresponding subscale scores, other than physical well-being, which represented the symptom burden of patients with cancer. Identically we can also see the phenomenon in factor analysis, factor loading of physical well-being in the physical domain was small at 0.188, whereas the psychological domain was high at 0.335. Symptom burden may nevertheless be distressing, if persistent, unrelieved, or ignored.21 Physical well-being, which was manifested in cachexia symptoms like pain, vomiting, insomnia, and fatigue in our survey, may affect the psychological status of the patients as well.22 Similarly, in the Korea15 version, factor loading of this item reached only 0.00 in the physical domain and, as in the present study, high factor loadings existed
in the psychological domain. In the validation in Hebrew,16 Physical well-being had high factor loadings in the physical and existential domains. This point reflected the heterogeneity within the cross-cultural application of scale, thus further strengthen the necessity of the cross-cultural validation test. In factor analysis, the result was basically consistent with the original English version, yet excluded the item 14 (every day seems a gift). Even cooperate with the correlation result, whether it interpreted the existential or the support domain stayed a critical problem. With further verification by means of CFA, original scale model is still slightly better than the new model, which concluded that the item 14 belongs to the support domain. We could infer from another perspective that maybe every day seems a gift could not just or fully explain only 1 dimension under the background of Chinese culture. Combined with religion differences, China’s religious faith (such as Buddhism) is far less prevalent than abroad (Christianity and Islam). And many people who had religious faith more concentrated among the minorities resided in Western region and rural areas,23 whereas the participants in our study mostly came from central region. So for people in this study, gift can be understood as the gratitude toward their families’ support or be interpreted as a negative emotion due to the self-exist burden they brought to the people around, rather than the strong feeling of the existence for another day, which belongs to the ‘‘god’s’’ gift. Annotation from the cultural level, China has more higher collectivism attitude compared to Western countries, which emphasize more in individualism.24 Feeling supported by the surroundings relates more with the collectivism than personal existence. Similar results could be seen from Japanese version of MQOL (MQOL-J) and Taiwan version in which item 14 loaded more in support domain. However in MQOL-HK, it still had the highest factor loading in psychological domain. Thus, we could see the culture and religion difference between those studies. For the feasibility study, patients could complete MQOL-C in less than 20 minutes and completed it on their own without seeking much help. Meanwhile, the correlation of psychological and support dimension with total score of the scales appeared most close. Conclusions could be drawn that the instrument was designed to be general in nature in order to maintain brevity and to assure applicability to all patients, which strongly supported its wide use. The internal consistency reliability also gets good results through Cronbach a value. In all QOL domains,3 out of 4 reach the recommending standard (>0.7) except the physical domain. Identically, test–retest reliability belongs to the stable coefficient. The aims at the validation of a scale laid more than the application under multicultural circumstances, but more vitally in the routine use for assessing internationally in specific aspects of quality of life. Thus, a tool for international comparison in clinical research was not only utilized in developed countries but also assessed in developing countries like Iran25 and Korean.15 So for patients experiencing with cancer, especially in China which is a developing country with a huge population base and increasing incidence of cancer, quality of their lives in palliative care setting becomes a burning problem, which is worthy of urgent attention.
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714 In comparison with previous studies on MQOL, no matter MQOL-HK,17 the Taiwan MQOL,16 or the MQOL-J study,26 the reliability and validity results are very similar with our study. Although MQOLQ is one of the most appropriate measures to evaluate the QOL, none of these measures score perfectly on all psychometric criteria, and their multifaith appropriateness requires further testing9 Through this prior validation study of MQOLQ, we hopefully provides a considerable, comprehensive tool for assessing quality of life among mainland Chinese patients with cancer. Further studies were needed for a large sample and multicenter study to test the convergent and divergent validity and the measurement sensitivity for the specific populations. Sex and face, which were part of the MQOL-HK, were not included in our scale on the consideration of bias. More research would be done to investigate these 2 items’ impact on QOL through a more scientific method.
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Acknowledgments The authors are much grateful for Prof C. Yuan and Prof Sheila Payne the productive discussion and valuable editorial improvement in this article. We would like to thank Dr Robin Cohen and her team for agreeing our translation of the MQOL for our study. We appreciate the industrious work from all the staff. Above all, we express our gratitude to all the patients for the participation in the research. This study could not be smoothly conducted without their contribution.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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