Climacteric

ISSN: 1369-7137 (Print) 1473-0804 (Online) Journal homepage: http://www.tandfonline.com/loi/icmt20

Serbian version of the Women’s Health Questionnaire: psychometric properties J. Dotlic, T. Gazibara, S. Radovanovic, B. Rancic, B. Milosevic, S. Nurkovic, I. Kurtagic & N. Kovacevic To cite this article: J. Dotlic, T. Gazibara, S. Radovanovic, B. Rancic, B. Milosevic, S. Nurkovic, I. Kurtagic & N. Kovacevic (2015) Serbian version of the Women’s Health Questionnaire: psychometric properties, Climacteric, 18:4, 643-650, DOI: 10.3109/13697137.2014.980402 To link to this article: http://dx.doi.org/10.3109/13697137.2014.980402

Accepted author version posted online: 06 Nov 2014. Published online: 27 Dec 2014. Submit your article to this journal

Article views: 22

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=icmt20 Download by: [York University Libraries]

Date: 05 November 2015, At: 14:07

CLIMACTERIC 2015;18:643–650

Serbian version of the Women’s Health Questionnaire: psychometric properties J. Dotlic*,‡, T. Gazibara†, S. Radovanovic‡, B. Rancic‡, B. Milosevic*, S. Nurkovic‡, I. Kurtagic‡ and N. Kovacevic‡ *Clinic for Obstetrics and Gynecology, Clinical Center of Serbia, Belgrade; †Institute for Epidemiology, Faculty of Medicine, University of Belgrade, Belgrade; ‡Faculty of Medicine, University of Belgrade, Belgrade, Serbia Key words: WOMEN’S HEALTH QUESTIONNAIRE, SCALE VALIDATION, MENOPAUSE, SERBIA

Downloaded by [York University Libraries] at 14:07 05 November 2015

ABSTRACT Objective The aim of this study was to translate the Women’s Health Questionnaire (WHQ) into the Serbian language and assess its validity and reliability in a population of Serbian menopausal women. Methods The study included peri- and postmenopausal women from two Community Health Centers in Belgrade. Women filled out the WHQ, the Short Form-36 questionnaire (SF-36) and Beck’s Depression Inventory (BDI). The WHQ was translated according to recommended methodology for cultural adaptation of questionnaires and its psychometric characteristics (internal consistency, inter-rater reliability, factor analysis, sensitivity, discriminant, construct and criterion validity) were tested. Results In the Serbian population, the mean values of the WHQ domains were mostly comparable with reference Mediterranean countries. Whole-scale Cronbach’s α was 0.838. Moreover, five WHQ domains had a value of Cronbach’s α above the acceptable limit. There were no significant differences in WHQ scores between our two investigators. On exploratory factor analysis, we obtained ten factors (two items formed a new factor – ‘Menstrual pathology’). Almost all SF-36 domains were significantly associated with WHQ domains, while the BDI was associated with domains: depressive mood, anxiety and sleep problems. Based on ROC analysis, WHQ is slightly more reliable for perimenopausal than postmenopausal Serbian women. Conclusion The Serbian version of the WHQ showed very good reliability and validity in assessment of quality of life among menopausal women. The WHQ is applicable for both peri- and postmenopausal women.

INTRODUCTION A considerable proportion of perimenopausal women present with numerous bothersome physical symptoms that can deteriorate quality of life1,2. Age-related reduced physical abilities and worsening of overall health can exacerbate the feelings of depression and/or loss of youth and femininity3,4. Apart from the physical aspect of mid-life, various socioeconomic changes, such as retirement, death of parents, friends and even partner or birth of grandchildren, may also occur in this particular period. These events can affect emotional well-being as well as social interactions of menopausal women5. Over the last decades, several instruments for assessing quality of life in peri- and postmenopausal women were developed for English-speaking populations6. However, only a few of

them have been translated and culturally adapted for worldwide use. Moreover, there are no Serbian versions of questionnaires or scales for evaluation of quality of life in menopause, although Serbia has a population of approximately 7 million people. Because of this, menopausal quality of life has not been explored in the Serbian population. In fact, only the Serbian version of the generic quality-of-life Short Form 36 (SF-36) questionnaire has been used for testing the influence of osteoporosis and urinary incontinency7,8. Furthermore, the economic transition and high unemployment rate in the Republic of Serbia may have predisposed to additional stress, making Serbian menopausal women a particularly vulnerable population group9,10. Given that no scales for assessment of quality of life in menopause have been used in the Serbian language, translating such an instrument would

Correspondence: Dr J. Dotlic, Clinic for Gynecology and Obstetrics, Clinical Center of Serbia, Visegradska 26, 11000 Belgrade, Serbia; E-mail: enadot@ yubc.net

ORIGINAL ARTICLE © 2014 International Menopause Society DOI: 10.3109/13697137.2014.980402

Received 26-07-2014 Revised 30-09-2014 Accepted 18-10-2014

Serbian version of WHQ be of paramount importance to highlight the most important factors that influence quality of life of menopausal women in Serbia. The aims of this study were to translate the Women’s Health Questionnaire (WHQ) into the Serbian language and to assess its validity and reliability in a population of Serbian menopausal women.

Dotlic et al. A total of 573 women were approached. Participation declined by as many as 373 women. All women who accepted participation in the study fulfilled the inclusion criteria. Therefore, 200 respondents comprised our study sample (response rate 39.4%).

Instruments METHODS

Downloaded by [York University Libraries] at 14:07 05 November 2015

Setting In the Republic of Serbia, the health-care system is organized according to three levels: primary, secondary and tertiary. The primary level of health care is provided in 157 stateowned Community Health Centers. One Community Health Center covers the territory of usually one or, in some cases, more municipalities or towns. According to law, all citizens should have access to a Community Health Center or an associated ambulatory center within 15 minutes travel distance. The team of chosen physicians in the Center consists of general practitioners and specialists in occupational medicine, pediatricians, gynecologists for women over 15 years and dentists11. According to Local Self-Government Bylaws, the municipalities of Belgrade, the capital of the Republic of Serbia, with a population of around 1.6 million inhabitants, are divided into the city center (n  10) and suburban outskirts (n  7)11. Hence, there are 17 Community Health Centers in the capital. Of all Centers, we randomly chose (by picking papers with their names from a bag) two to conduct the study: one from the central districts and one from the outskirts. We had one investigator in each Center who administered questionnaires to women before regular check-ups by their chosen gynecologists. The study was approved by the Institutional Review Boards of the two corresponding Community Health Centers. All subjects signed informed consent before enrollment in the study.

Participants All consecutive peri- and postmenopausal women who had regular check-ups in the two Community Health Centers in Belgrade over a 4-month period (1st February–1st June 2014) were recruited for this study. Inclusion criteria were: age range 40–65 years, being perimenopausal (having irregular cycles and climacteric symptoms or last menstrual period less than 12 months ago) or postmenopausal (last menstrual period 1 year ago), speaking Serbian fluently, and giving signed informed consent. The exclusion criteria were: verified psychiatric diseases or severe chronic conditions (malignancies, neurological, acute deterioration of chronic illness, etc.) that could affect quality of life, declining participation, giving less than 90% of required answers, and not fulfilling the inclusion criteria.

644

The WHQ is a 37-item, self-administered, specific instrument providing a detailed assessment of minor psychological and somatic symptoms experienced during the peri- and postmenopausal periods12. The items are combined into nine dimensions: depressed mood (DEP, seven items), somatic symptoms (SOM, seven items), memory/concentration (MEM, three items), vasomotor symptoms (VAS, two items), anxiety/ fears (ANX, four items), sexual behavior (SEX, three items), sleep problems (SLE, three items), menstrual symptoms (MEN, four items), and attractiveness (ATT, two items). There is no summary WHQ score. All items are rated on a four-point Likert scale (graded from ‘yes, definitely’ to ‘no, not at all’). To simplify scoring, item scores are reduced to the binary scale, where values 0 correspond to negative answers (originally marked as 3 and 4) and values 1 correspond to affirmative answers (originally marked as 1 and 2). Subsequently, nine subscores for each domain are calculated as the mean of binary values of all items included in the domain. This means that all nine domain scores range from 0 to 112. Higher scores of domains indicate worse health status, while scores closer to 0 indicate better health status. There are no cut-off values for the nine scores. Also, in order for a domain to be valid, there are not supposed to be more than two missing values for each domain. However, in case women did not have menstrual periods or were sexually active (items #26, #31 and #34), those items were to be left unanswered. This means that these unanswered items were not considered as missing items, but rather as ‘option five’. Moreover, according to scoring guidelines, items #13 and #37 did not belong to any domain. Therefore, a total of 35 questions are rated and are included in the WHQ domains12,13. Apart from the WHQ, which is the specific quality-of-life instrument, women filled out the generic quality-of-life instrument, the Short Form-36 questionnaire (SF-36), and Beck’s Depression Inventory (BDI). Serbian versions of these two questionnaires are widely used in population surveys. The SF-36 questionnaire is the most widely used generic, healthrelated quality-of-life instrument, testing eight different quality-of-life dimensions: physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional and emotional well-being. Based on these domains, two summary scores are constructed: Physical Health Composite score (PHC) and Mental Health Composite score (MHC). Finally, the total quality-of-life score is calculated from PHC and MHC. Scores in the scale range from 0 to 100 and higher values indicate a better quality of life14. The BDI is a 21-item scale designed to measure severity of depression and impact of depression on quality of life. Answers are graded from 0 to 3.

Climacteric

Serbian version of WHQ BDI scores higher than 21 are considered to indicate presence of depression in the general population15. Finally, sociodemographic characteristics and detailed gynecological history were taken from all study participants.

Downloaded by [York University Libraries] at 14:07 05 November 2015

Translation of the WHQ Approval to use the WHQ in our study was obtained from the scale author (Dr Hunter) and the MAPI Research Trust. The WHQ was translated according to the internationally accepted methodology for cultural adaptation of a questionnaire16. The purpose was to generate a version that was semantically and conceptually as close as possible to the original questionnaire. Translation of the original English WHQ (‘forward translation’) into the Serbian language was performed by two independent translators. The ‘backward translation’ (from Serbian back to English) was completed by the third translator, who was blinded to the original questionnaire. Afterwards, translators discussed all items to generate a version of the WHQ which would be the most appropriate for the cultural environment of Serbia and acceptable for testing menopausal women. To check the understanding and interpretation of the translated items by the Serbian population, the questionnaire was tested on 15 women. As there were no remarks on clarity and understanding of items, the final version was generated and applied in this study.

Statistical analysis We used methods of descriptive and analytical statistics to illustrate in short the study population, as well as to present the SF-36 and BDI scores and marks of specific symptoms of WHQ. Scale reliability was evaluated by testing internal consistency and inter-rater reliability. Internal consistency of the Serbian version of the WHQ was evaluated using Cronbach’s α16. This coefficient shows correlations between scale items. Values above 0.7 are considered statistically appropriate17. Inter-rater reliability, which shows the compliance of results achieved by different researchers, was tested by the Kruskal–Wallis test (non-parametric ANOVA)16. Hotelling T-square test (HT2) is a multivariate test for the null hypothesis stating that all items on the scale have the same mean. It was applied to test the significance of differences between obtained mean score values of all WHQ items together and the hypothetic case in which items have equal scores17. Discriminating characteristics of the scale items were tested by corrected item–total correlation (CI–TC) analysis. It shows the relationships of one item with the score of the remaining scale items. The item is considered as an adequate part of the scale if CI–TC is   0.4016. To evaluate construct validity, an exploratory factor analysis (principal component analysis with Varimax rotation) was performed. A factor is considered important if its eigenvalue

Climacteric

Dotlic et al. is above 1.0. Factor loadings indicate correlation coefficients between the scale items and established factors. The communality index represents the variance of the scale item accounting for all factors16. To exclude common method bias (CMB), we performed Harman’s single factor test (confirmatory factor analysis) with Promax rotation. If CMB is an issue, a single factor will account for the majority of the variance in the model16. The criterion validity of the WHQ was assessed by correlating (Spearman’s correlation) the WHQ score with BDI and SF-36 scores16. To determine factors associated with the WHQ, we performed the Enter method of multiple linear regression analysis. Dependent variables in the models were WHQ domains. Independent variables were women’s characteristics (age, age at menopause, parity), BDI and SF-36 scores (according to domains, composite and total scores). Finally, we performed ROC analysis to determine the sensitivity and specificity of WHQ domains according to menopausal status (perimenopausal vs. postmenopausal).

RESULTS The study included 200 peri- and postmenopausal women with mean   standard deviation age of 52.55   6.12 years, up to eight pregnancies and up to three births. The average   standard deviation age of menopause was 47.04   5.08 years. There were significantly more menopausal women (n  115, 57.5%) while 85 women (42.5%) still had regular menstrual cycles (χ2  4.500; p  0.034). The average WHQ domain scores are presented in Table 1. All item scores were heterogeneous and not normally distributed (p  0.001). The highest score was achieved for item #8 (I feel life is not worth living), while item #25 (I have feelings of well-being) received the lowest marks. Mean values of DEP, SOM and MEM were similar to referral scores in the French

Table 1

Average domain scores of WHQ

Domain

Mean

Standard deviation

Median

Cronbach’s a

Depressed mood – DEP Somatic symptoms – SOM Memory/concentration – MEM Vasomotor symptoms – VAS Anxiety/fears – ANX Sexual behavior – SEX Sleep problems – SLE Menstrual symptoms – MEN Attractiveness – ATT

0.26 0.47

0.24 0.29

0.15 0.43

0.569 0.751

0.44

0.39

0.33

0.728

0.44

0.43

0.50

0.777

0.34 0.33 0.43 0.41

0.34 0.31 0.40 0.33

0.25 0.33 0.33 0.33

0.786 0.201 0.786 0.471

0.24

0.35

0.00

0.597

645

Downloaded by [York University Libraries] at 14:07 05 November 2015

Serbian version of WHQ population18. Domains of VAS and ANX were almost equal to the referral population in Italy19. Likewise, the SLE domain corresponded to scores in France and Italy18. In addition, the mean value for SEX domain was the same as referral values in German women19. In contrast, the mean value of MEN was the highest, while that of ATT was the lowest compared with all referral countries19. The whole-scale Cronbach’s α was 0.838. Cronbach’s α based on standardized items was 0.847. Cronbach’s α values for the WHQ domains are presented in Table 1. The Hotelling T square test value was highly significant (HT2  128.355; F  15.480; p  0.001). The values of the CI–TC coefficients for the WHQ in the Serbian population were higher than 0.40 for 20 items. The CI–TC values were the lowest for items #10 (I have a good appetite), #26 (I have heavy periods) and #32 (I feel physically attractive). Cronbach’s α if an item deleted was above 0.800 for all items. It was the highest if item #31 (I am satisfied with my current sexual relationship) and #32 (I feel physically attractive) were deleted: 0.863, and the lowest if item #19 (I have hot flushes) was deleted: 0.845. The majority of women considered item #13 (I worry about growing old) occasionally applicable for them (χ2  6.480, p  0.011). Answers to question #37, that highlights previously mentioned symptoms that are most disabling, showed that, in most cases (n  181; 90.5%), women did not have a specific predominant symptom. Still, the symptoms that were mostly pointed out were #28 (bloated stomach), #29 (difficulties in getting off to sleep), #33 (concentration problems), #35 (frequent urination) and #36 (poor memory). We obtained ten factors on factor analysis. Apart from nine standard ones (Depressed mood, Somatic symptoms, Memory/ concentration, Vasomotor symptoms, Anxiety/fears, Sexual behavior, Sleep problems, Menstrual symptoms, Attractiveness) in our population, two questions: items #22 and #26, originally part of Menstrual symptoms, formed a new factor – ‘Menstrual pathology’. The achieved ten factors explained 71.42% of variance, while the nine original factors explained 68.57% (Table 2). CMB was not present as our single factor accounted for only 32.16% variance. There were no significant differences in either of the WHQ scores between our two investigators (DEP: χ2  0.943, p  0.331; SOM: χ2  0.018, p  0.895; MEM: χ2  0.009, p  0.922; VAS: χ2  2.366; p  0.124; ANX: χ2  0.002, p  0.965; SEX: χ2  0.036, p  0.849; SLE: χ2  0.037, p  0.847; MEN: χ2  0.255, p  0.614; ATT: χ2  2.557, p  0.110). Upon performing the analysis, our two raters found similar results, which implies adequate translation and reliability of the WHQ. The majority of examined women were not depressed (mean BDI  6.68   7.24). Total quality of life assessed by the SF-36 questionnaire ranged from 20.75 to 97.50 (mean  71.47   14.36). Correlation coefficients between domains of WHQ and the SF-36 as well as the BDI are presented in Table 3. All correlations were statistically significant, except those for BDI and VAS. In addition, role physical domain was not correlated with VAS, ATT and SEX, while

646

Dotlic et al. Vitality and Social functioning domains were not correlated with SEX. All other SF-36 domains were significantly correlated with all WHQ domains. According to multiple linear regression analysis, nine statistically significant equations of relationship between WHQ and SF-36 scores, BDI, women’s age, age at menopause and parity together were obtained (Table 4). Almost all SF-36 domains were proven as predictors of WHQ domains, which confirmed the validity of the WHQ. Results of ROC analysis are presented in Table 5. Sensitivity was better than specificity for all domains. We found that DEP is equally applicable in both groups. Domains SOM, MEM, VAS, ANX and especially SEX are more reliable in the population of perimenopausal women, while MEN and ATT give more consistent data for postmenopausal women.

DISCUSSION Our study demonstrated that the Serbian version of the WHQ had adequate psychometric properties and was acceptable for our menopausal women. High values of the CI–TC coefficient for the majority of scale items confirmed that they are appropriate parts of the WHQ. The ROC analysis applied in this study confirmed that the WHQ can be used in peri- and postmenopausal women, although better sensitivity was achieved for symptoms of perimenopausal women. Menopause-related symptoms and psychosocial problems as well as the meanings of menopause may differ considerably among nationalities. Therefore, ethnicity and culture issues should be considered when adopting the correct questionnaire for quality-of-life assessment20. Although two versions of the WHQ are available (the longer with 37 items and the shorter with 23 items), we specifically chose the original, longer one because it covers more diverse symptoms, especially regarding sexual behavior and attractiveness. Our results indicated that there were some particularities concerning these two domains in the Serbian population, which could be attributable to cultural distinctiveness. Moreover, item #13, which is not included in the scoring, but rather analyzed separately, provided us with quite important data. Based on the minimal (#25) and maximal (#8) scores per item, it can be observed that Serbian menopausal women have poor overall happiness, but still strongly value life. All mean WHQ scores in our population corresponded to average reference values in other Mediterranean countries included in the original questionnaire validation (France and Italy)18,19. These findings are not surprising, because Serbia shares a similar temperament, diet, geographic and historic background with the surrounding countries. Conversely, the feeling of attractiveness among Serbian menopausal women was rated much better than in all reference populations. This could be explained by the current trend of being fit and good-looking all the time, at all costs. The fact that a significant percentage of women in our study occasionally worry about growing old (item #13) supports the previous observation.

Climacteric

Serbian version of WHQ Table 2

Principal component analysis of the Serbian WHQ version with Varimax rotation

Domain DEP

SOM

Downloaded by [York University Libraries] at 14:07 05 November 2015

Dotlic et al.

MEM

VAS ANX

SEX

SLE

MEN ATT MP

WHQ items

Communality index

Variance

#3 I feel miserable and sad #5 I have lost interest in things #7 I still enjoy the things I used to #8 I feel life is not worth living #10 I have a good appetite #12 I am more irritable than usual #25 I have feelings of well-being # 14 I have headaches # 15 I feel more tired than usual # 16 I have dizzy spells # 18 I suffer from backache or pain in my limbs # 23 I feel sick or nauseous # 30 I often notice pins and needles in my hands and feet # 35 I need to pass urine/water more frequently than usual # 20 I am more clumsy than usual # 33 I have difficulty in concentrating # 36 My memory is poor # 19 I have hot flushes # 27 I suffer from night sweats # 2 I get very frightened or panic feelings for apparently no reason at all # 4 I feel anxious when I go out of the house on my own # 6 I get palpitations or a sensation of ‘butterflies’ in my stomach or chest # 9 I feel tense or ‘wound up’ # 24 I have lost interest in sexual activity # 31 I am satisfied with my current sexual relationship # 34 As a result of vaginal dryness sexual intercourse has become uncomfortable # 1 I wake early and then sleep badly for the rest of the night # 11 I am restless and can’t keep still # 29 I have difficulty in getting off to sleep # 17 My breasts feel tender or uncomfortable # 28 My stomach feels bloated # 21 I feel rather lively and excitable # 32 I feel physically attractive # 22 I have abdominal cramps or discomfort # 26 I have heavy periods

0.701 0.639 0.799 0.807 0.763 0.695 0.722 0.798 0.633 0.641 0.709 0.659 0.783 0.626 0.761 0.665 0.739 0.679 0.742 0.710 0.663 0.744 0.753 0.795 0.825 0.657 0.676 0.794 0.667 0.619 0.649 0.764 0.675 0.734 0.708

26.51

8.89

7.04

5.61 4.93

4.58

3.94

3.74 3.29 2.86

DEP, Depressed mood; SOM, Somatic symptoms; MEM, Memory/concentration; VAS, Vasomotor symptoms; ANX, Anxiety/fears; SEX, Sexual behavior; SLE, Sleep problems; MEN, Menstrual symptoms; ATT, Attractiveness; MP, Menstrual pathology – newly extracted Table 3 Spearman correlation coefficients for association between WHQ domain scores, depression and generic QOL scores Scales Depressed mood – DEP Somatic symptoms – SOM Memory/concentration – MEM Vasomotor symptoms – VAS Anxiety/fears – ANX Sexual behavior – SEX Sleep problems – SLE Menstrual symptoms – MEN Attractiveness – ATT

Beck Depression Inventory

Physical Health Composite

Mental Health Composite

Total Quality of Life

0.372 0.289 0.325 0.102* 0.430 0.343 0.302 0.247 -0.292

0.465 0.515 0.405 0.266 0.492 0.193 0.372 0.399 0.235

0.575 0.544 0.492 0.265 0.590 0.227 0.489 0.370 0.285

0.562 0.578 0.493 0.278 0.594 0.232 0.473 0.408 0.272

*, Not significant

Climacteric

647

Serbian version of WHQ

Dotlic et al.

Table 4 Factors associated with quality of life in menopause as measured by the WHQ Equations

Downloaded by [York University Libraries] at 14:07 05 November 2015

DEP  60.284 – 0.186  SF – 0.252  GH – 0.328  PF  0.241  BDI SOM  5.641 – 0.285  V – 0.364  GH MEM  37.182 – 0.289  SF – 0.208  RE VAS  19.329 – 0.668  V – 0.384  SF – 1.095  MA ANX  19.383 – 0.336  V – 0.454  GH – 0.843  EW  0.646  BDI SEX  44.507 – 0.216  RE – 0.549  EW – 1.658  Age MEN  11.014 – 0.698  TQL SLE  71.173 – 0.444  GH – 0.552  EW  0.936  BDI – 1.096  MA ATT  36.679 – 1.007  Age – 0.459  EW – 0.268  PF  0.977  MA

R

Adjusted R2

F

p

0.354 0.722 0.639 0.552 0.758 0.663 0.587 0.731 0.554

0.102 0.460 0.331 0.214 0.519 0.367 0.259 0.474 0.217

5.263 8.400 5.296 3.370 10.385 6.047 4.044 8.834 3.407

0.002 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001

DEP, Depressed mood; SOM, Somatic symptoms; MEM, Memory/concentration; VAS, Vasomotor symptoms; ANX, Anxiety/fears; SEX, Sexual behavior; SLE, Sleep problems; MEN, Menstrual symptoms; ATT, Attractiveness; PF, physical functioning; GH, general health; RE, role emotional; V, vitality; SF, social functioning; EW, emotional well-being; MHC, mental composite score; TQL, total quality of life; BDI, Beck Depression Inventory; MAS, menopause age

Cronbach’s α for the whole scale of 0.838 demonstrated excellent internal consistency of the WHQ in the Serbian population. Comparable coefficients were obtained in other cultural settings (Italian, Swedish, Turkish and Portuguese)20–23. Domains of SOM, MEM, VAS, ANX and SLE also had adequate values of Cronbach’s α. Moreover, these coefficients were quite close to those in other populations20–23. On the other hand, Cronbach’s α for DEP, MEN and ATT domains was lower than the standard cut-off of 0.7. Nevertheless, in other available validations, Cronbach’s α ranged from 0.56 to 0.817. However, we obtained the lowest value of Cronbach’s α for sexual behavior (α  0.201) compared to all other validations12,20–23. We identified numerous correlations of WHQ domains and domains of the generic SF-36 questionnaire. For instance, those who have better social and physical functioning and general health feel depressed less often. Also, if memory and concentration are satisfactory, women have better social functioning and emotional role. This could also mean that they are appropriately responding to challenges at work. Additionally, good memory enables them to maintain contacts and engage in meaningful conversations with their friends, which is also

important in terms of overall quality of life. We identified that being anxious was related to physical (vitality and general health) as well as mental aspects (emotional well-being and depression). Given that anxiety is one of the key features of mental health, our study of menopausal women supported this correlation. Furthermore, the relationship of anxiety and physical functioning could be interpreted in a manner that physical changes in menopause could be overwhelming and upsetting as well. Fewer somatic symptoms (lower scores closer to 0) were noted for women with higher levels of vitality and general health. In line with this, predictors of vasomotor symptoms were vitality, social functioning and age at menopause. In contrast, vasomotor symptoms did not deteriorate feeling of attractiveness and physical functioning, nor did they enhance depression level. Sleep problems, on the other hand, were related to worse general health and emotional well-being, depression and earlier menopause. As expected, women with less menstrual symptoms had higher values of total quality of life. Our findings were similar to those in the literature1–5,20–23. Satisfactory sexual practice, as expected, was registered in younger women with highly rated emotional role and well-

Table 5 Coordinates and area under the ROC curve according to menopausal status Explained cases (%) Domain Depressed mood – DEP Somatic symptoms – SOM Memory/concentration – MEM Vasomotor symptoms – VAS Anxiety/fears – ANX Sexual behavior – SEX Sleep problems – SLE Menstrual symptoms – MEN Attractiveness – ATT

648

Perimenopausal

Postmenopausal

Cut-off WHQ value

Sensitivity (%)

Specificity (%)

50 53.8 57.2 61.0 53.0 66.8 59.9 49.2 45.5

50 46.2 42.8 39.0 47.0 33.2 40.1 50.8 54.5

0.50 0.45 0.50 0.42 0.54 0.50 0.39 0.52 0.42

84 69 62 57 59 52 64 68 87

32 26 32 22 27 20 15 37 22

Climacteric

Downloaded by [York University Libraries] at 14:07 05 November 2015

Serbian version of WHQ being. In contrast, sexual domain of the WHQ demonstrated inadequate Cronbach’s α. Because questionnaire guidelines indicated that women who are not sexually active skip answering sex-related items, it may have extremely decreased Cronbach’s α. Our results indicate that a high percentage of older women either do not have a partner (single, divorced, widowed) or they reduce sexual activity even if they had a partner. This was supported by the finding that sexual behavior did not correlate with physical parameters and social interactions with friends and working environment. In addition, younger women felt more attractive, which may be indicative that older, postmenopausal women reduce sexual activities because they do not feel attractive or desirable any longer. Then again, numerous omitted answers may also reflect cultural barriers, i.e. that women feel uncomfortable discussing their sexual practices in a questionnaire. Similar observations have been noted in validation of a quality-of-life scale for multiple sclerosis in the Serbian language, where the highest proportion of missing answers referred to sexrelated items24. Some limitations of our study should be addressed. The study was designed as cross-sectional, which can only be indicative but not provide causality or direction of a relationship. This survey was administered only to women who lived in the metropolitan area of the capital city, whereas women from rural areas were omitted. However, our sample was drawn from Community Health Centers, which are referral primary health-care centers for the surrounding municipality including women from various socioeconomic backgrounds in the largest Serbian city. Moreover, women in our sample came from both suburban and central city districts and therefore our results may be applicable to

Dotlic et al. postmenopausal women living in other urban areas in the country. A somewhat low response rate can be due to the cultural specificity of Serbian menopausal women who are not used to studies regarding their quality of life and might feel embarrassed to comment on symptoms that they are experiencing. In conclusion, the cross-culturally adapted Serbian version of the WHQ for testing quality of life among menopausal women showed very good reliability and validity. Our findings indicate that the WHQ could be used among perimenopausal as well as in postmenopausal women, although it is slightly more reliable for perimenopausal women. Finally, the WHQ possesses appropriate psychometric characteristics and therefore can be used in daily clinical work with menopausal women in the Serbian language.

ACKNOWLEDGEMENTS We sincerely appreciate Dr Myra Hunter and the MAPI Research Trust for allowing us to adapt the original version of the WHQ. The authors would like to express gratitude to the two Community Health Centers in Belgrade (‘Vracar’ and ‘Rakovica’) for allowing us to conduct this study using their patients and facilities. Finally, we would like to thank all participants for taking interest in our study. Conflict of interest The authors declare no potential confl icts of interest. The authors alone are responsible for the content and writing of this study. Source of funding

Nil.

References 1. Nisar N, Sohoo NA. Frequency of menopausal symptoms and their impact on the quality of life of women: a hospital based survey. J Pak Med Assoc 2009;59:752–6 2. Ceylan B, Ozerdogan N. Menopausal symptoms and quality of life in Turkish women in the climacteric period. Climacteric 2014;17:705–12 3. Greenblum CA, Rowe MA, Neff DF, Greenblum JS. Midlife women: symptoms associated with menopausal transition and early postmenopause and quality of life. Menopause 2013;20: 22–7 4. Matthews KA, Bromberger JT. Does the menopausal transition affect health-related quality of life? Am J Med 2005;118(Suppl 12B):25–36 5. Chedraui P, San Miguel G, Avila C. Quality of life impairment during the female menopausal transition is related to personal and partner factors. Gynecol Endocrinol 2009;25: 130–5 6. Zollner YF, Acquadro C, Schaefer M. Literature review of instruments to assess health-related quality of life during and after menopause. Qual Life Res 2005;14:309–27 7. Mladenovic Segedi L, Segedi D, Parezanovic Ilic K. Quality of life in women with urinary incontinence. Med Glas (Zenica) 2011;8:237–42

Climacteric

8. Tadic I, Vujasinovic Stupar N, Tasic L, et al. Validation of the osteoporosis quality of life questionnaire QUALEFFO-41 for the Serbian population. Health Qual Life Outcomes 2012;10:74 9. Statistical Office of the Republic of Serbia. Available at http:// webrzs.stat.gov.rs/WebSite/ 10. Jankovic J, Simic S, Marinkovic J. Inequalities that hurt: Demographic, socio-economic and health status inequalities in the utilization of health services in Serbia. Eur J Public Health 2010:20:389–96 11. WHO Regional Office for Europe. Evaluation of the organization and provision of primary care in Serbia. Primary care in the WHO European Region. (2010) Available at http://www.euro. who.int/__data/assets/pdf_file/0005/128849/e94554.pdf 12. Hunter MS. The Women’s Health Questionnaire (WHQ): The development, standardization and application of a measure of mid-aged women’s emotional and physical health. Qual Life Res 2000;9:733–8 13. Hunter MS. The Women’s Health Questionnaire: A measure of mid-aged women’s perceptions of their emotional and physical health. Psychol Health 1992;7:45–54 14. Ware JE, Snow KK, Kosinski M, Gandek B. The SF-36 Health Survey Manual and Interpretation Guide. Boston: Nimrod Press, 1993

649

Serbian version of WHQ

21.

22.

23.

24.

and those attending menopause centers. Climacteric 2002; 5:70–7 Wiklund I, Karlberg J, Lindgren R, Sandin K, Mattsson LA. A Swedish version of the Women’s Health Questionnaire – A measure of postmenopausal complaints. Acta Obstet Gynecol Scand 1993;72:648–55 Erci B, Gungormus Z, Ozturk S. Psychometric validation of the Women’s Health Questionnaire in menopausal women. Health Care Women Int 2014;35:566–79 Da Silva Filho CR, Ferraz MB. Quality of life in menopause: Validation of women’s health questionnaire in Brazil. J Clin Epidemiol 1999;52:25S Pekmezovic T, Kisic Tepavcevic D, Kostic J, et al. Validation and cross-cultural adaptation of the disease-specific questionnaire MSQOL-54 in Serbian multiple sclerosis patients sample. Qual Life Res 2007;16:1383–7

Downloaded by [York University Libraries] at 14:07 05 November 2015

15. Beck AT, Beck RW. Screening depressed patients in family practice: a rapid technique. Postgrad Med 1972;52: 81–5 16. Guillemin F. Cross-cultural adaptation and validation of health status measures. Scand J Rheumatol 1995;24:61–3 17. Bland JM, Altman DG. Cronbach’s alpha. Br Med J 1997;317:572 18. Girod I, de la Loge C, Keininger D, Hunter MS. Development of a revised version of the Women’s Health Questionnaire. Climacteric 2006;9:4–12 19. IQOD-Women Health’s Questionnaire user manual (2004). Available at http://www.mapi-research-inst.com and http://www. iqod.org 20. Genazzani AR, Nicolucci A, Campagnoli C, et al. Validation of Italian version of the Women’s Health Questionnaire: assessment of quality of life of women from the general population

Dotlic et al.

650

Climacteric

Serbian version of the Women's Health Questionnaire: psychometric properties.

The aim of this study was to translate the Women's Health Questionnaire (WHQ) into the Serbian language and assess its validity and reliability in a p...
405KB Sizes 0 Downloads 8 Views