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ISSN: 1369-7137 (Print) 1473-0804 (Online) Journal homepage: http://www.tandfonline.com/loi/icmt20
Validation of the traditional Chinese version of the Menopausal Rating Scale with WHOQOL-BREF H-c. Wu, S-h. Wen, J-s. Hwang & S-c. Huang To cite this article: H-c. Wu, S-h. Wen, J-s. Hwang & S-c. Huang (2015) Validation of the traditional Chinese version of the Menopausal Rating Scale with WHOQOL-BREF, Climacteric, 18:5, 750-756, DOI: 10.3109/13697137.2015.1044513 To link to this article: http://dx.doi.org/10.3109/13697137.2015.1044513
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Date: 06 November 2015, At: 01:08
CLIMACTERIC 2015;18:750–756
Validation of the traditional Chinese version of the Menopausal Rating Scale with WHOQOL-BREF
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H-C. Wu*,†, S-H. Wen‡, J-S. Hwang** and S-C. Huang††,‡‡ *Division of Chinese Gynecology and Pediatrics, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City; †School of Post-baccalaureate Chinese Medicine, Tzu Chi University, Hualien; ‡Department of Public Health, College of Medicine, Tzu Chi University, Hualien; **Institute of Statistical Science, Academia Sinica, Taipei; ††Department of Obstetrics and Gynecology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City; ‡‡School of Medical, Tzu Chi University, Hualien, Taiwan Key words: MENOPAUSAL SYMPTOMS, CLIMACTERIC, QUALITY OF LIFE, MENOPAUSAL RATING SCALE – TRADITIONAL CHINESE VERSION, WHOQOL-BREF, RELIABILITY, VALIDITY
ABSTRACT Objective To assess the criterion validity, construct validity and test–retest reliability of the traditional Chinese language version of the Menopause Rating Scale (MRS-TC version). Methods This was an observational, cross-sectional study covering hospital and community samples of 317 women aged 39–62 years. Two questionnaires were administered, namely, the MRS-TC version, made up of 11 items in three dimensions, and the World Health Organization Quality of Life-BREF (WHOQOLBREF). The intraclass correlation coefficient was used to examine the test–retest reliability of the questionnaire on two separate occasions, 2 weeks apart. The internal consistency was assessed with Cronbach’s α. To evaluate criterion validity, the relationship between the individual items and dimension scores of both instruments was estimated. Pearson’s correlation was used to assess convergent and discriminant validity; construct validity was evaluated by comparing the mean scores of menopausal and non-menopausal women for each of the MRS dimensions. Results The final questionnaire comprised 11 items in three dimensions. The intra-class correlation (ICC) for the test–retest reliability ranged from 0.83 to 0.93; values of Cronbach’s α for psychological, somatic, and urogenital symptom domains were 0.88, 0.68, and 0.59, respectively. For the convergent and discriminant validity, the correlations between the individual questionnaire and the WHOQOL-BREF were significant; those with the MRS dimensions were significantly negatively associated for the physical, psychological, social and environmental domains. Conclusion The MRS-TC version using the traditional Chinese language is a reliable and valid questionnaire for assessing menopausal symptoms and global quality of life in climacteric women.
INTRODUCTION Quality of life is a subjective perception modified by the cultural context in which one lives. Assessing quality of life during the female climacteric is complex, as it involves changes occurring from physiological, psychological, sexual, social and familial points of view. Various tools have been designed to assess health-related quality of life during and after the
menopause1; one such tool is the Menopause Rating Scale (MRS) which measures the severity of menopausal symptoms. The MRS is a formally validated scale for measuring the impact of climacteric symptoms and assessing health-related quality of life of women in the menopausal transition2. The nine currently available language versions have been translated following international standards for the linguistic and cultural translation of quality-of-life scales3. However, the
Correspondence: Dr H-C. Wu, Division of Chinese Gynecology and Pediatrics, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jianguo Rd., Xindian Dist., New Taipei City 23142, Taiwan; E-mail: [email protected] ORIGINAL ARTICLE © 2015 International Menopause Society DOI: 10.3109/13697137.2015.1044513
Received 27-02-2015 Revised 20-04-2015 Accepted 20-04-2015
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Validation of Chinese version of Menopausal Rating Scale traditional Chinese version of the Menopausal Rating Scale (MRS-TC version) has to date only been translated but not validated and the contents (explanation of the 11 symptoms) of the MRS-TC version on the website are not entirely the same as in the original English version. The reason why MRS can be linked to quality of life is because it compares with the previous quality-of-life scale Short Form-36 (SF-36)2. According to the World Health Organization (WHO) definition, quality of life is an individual’s perception of their status in life, in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns4. However, if we consider the comprehensive terms of global quality of life, it not only involves the physiological and psychological, but also regarding interest in life, sexuality, maintenance of good social relationships, and a general feeling of wellness5. Estrogen deficiency in menopausal women can cause urogenital atrophy which leads to symptoms such as vaginal dryness, dyspareunia, dysuria, urge incontinence and loss of libido. The effects of these urogenital symptoms on general well-being are not only decided by the kind and severity of the symptoms but also by the individual’s psychosocial adaptation to them. In particular, the sexual problems of menopausal women are part of the social aspect of quality of life and also closely related to interpersonal relationships6. Our thesis also used the World Health Organization Quality of Life-BREF (WHOQOL-BREF), an enhanced type of general quality-oflife instrument developed by the WHOQOL Group, as compared with the MRS, and aimed to assess the criterion validity, construct validity and test–retest reliability of the MRS-TC version.
MATERIALS AND METHODS This survey was conducted among women who had perceived menopausal-related symptoms or not at the Taipei Tzu Chi Hospital or among community participants in the northern urban region of Taiwan (Republic of China). We collected data for a total of 317 participants who met the study criteria between March 2013 and December 2013 and this protocol was approved by the Institutional Ethics Committee of the Taipei Tzu Chi Hospital. All participants provided signed and informed consent.
Participants We recruited participants aged between 39 and 62 years from outpatients at gynecological clinics and from the community. Menopausal status was classified into pre-, peri- and postmenopausal. Premenopausal women were defined as having regular menstrual periods for at least 12 months prior to enrollment. Postmenopausal women were defined as having at least 1 year without menstruation and perimenopausal women were defined as those undergoing abnormal vaginal bleeding or unusual menstrual cycle lengths for the year prior
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Wu et al. to enrollment. Every participant was requested to fill out questionnaires on demographic characteristics, previous history of chronic diseases, current menstrual status, menopausal symptoms, the MRS-TC version, and the WHOQOL-BREF Taiwan version. Participants were included if they were aged around the climacteric stage and were willing to participate. Participants who had a history of cancer, psychiatric disorders, stroke, or any other disease that might significantly affect their quality of life or who had serious disability affecting their ability to communicate and answer the instruments were excluded.
Instruments MRS-TC version The translation procedure followed recognized guidelines7,8; for details of the steps, see the Supplementary Appendix to be found online at http://informahealthcare.com/doi/abs/10.3109 /13697137.2015.1044513. In the MRS-TC version questionnaire, consisting of 11 symptoms, each item was graded from 0 to 4 (0, not present; 1, mild; 2, moderate; 3, severe; 4, very severe)9. The accumulated total scale could be further divided into three subscales: (1) somatovegetative – sweating/hot flushes, heart discomfort, sleep problems and joint and muscular discomfort; (2) psychological – depressive mood, irritability, anxiety and physical and mental exhaustion; (3) urogenital – sexual problems, bladder problems and vaginal dryness. With every symptom, as in the original English version of the questionnaire, was a detailed explanation of this symptom. A total MRS-TC score was calculated as the sum of all the individual subscale scores. Participants were asked to report the menopausal symptoms shown in the MRS-TC as experienced in the previous 2 weeks.
Taiwan version of WHOQOL-BREF The Taiwan version of WHOQOL-BREF was simplified from the original WHOQOL-100 Taiwan questionnaire. The WHOQOL-BREF comprises four domains containing 24 aspects, plus two national items on overall quality of life and general health10,11. There are a total of seven items in the physical domain (pain and discomfort (LQ3), energy and fatigue (LQ10), sleep (LQ16) and rest, mobility, daily living activities, dependence on medication and working capacity), six in the psychological domain (positive feelings, thinking and concentration, self-esteem, physical image and appearance, negative feelings (LQ26) and spiritual/religious/personal beliefs), three in the social domain (personal relationships, social support and especially sexual activity (LQ21)), and eight in the environmental domain. Each item was scored on a Likert scale ranging from 1 to 5, with a higher score indicating a favorable condition after reversing the direction of several items that were originally posed in a negative way. In order to standardize the domain scores for comparison, the average score of each domain was calculated and then
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multiplied by 4, as recommended by the WHOQOL4. Thus, the domain scores ranged from 4 to 20, with a higher score indicating a better quality of life on the corresponding domain. The reliability and validity were good11,12.
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Statistical analysis We first conducted a descriptive analysis of sample characteristics and instruments. Individual items of the MRS-TC version and domains of the WHOQOL-BREF and MRS-TC version were also assessed for the different menopausal status. One-way analysis of variance followed by Fisher’s least significant difference test and the χ2 test were used to ascertain the significance of the differences between the mean values and each pair of continuous variables. The floor and ceiling effects of the MRS-TC version were assessed by calculating the proportion of subjects who scored minimum and maximum values, separately. We used the intra-class correlation coefficient (ICC) to examine the test–retest reliability of the MRS-TC version. A total of 193 participants provided repeated responses within a 2-week interval by the same evaluator. Internal consistency reliability was evaluated using Cronbach’s α coefficient. Each value of the coefficient that was greater than 0.7 indicated satisfactory agreements. Pearson’s correlation was applied to evaluate convergent and discriminant validity. It had adequate convergent validity when the correlation coefficient between the score for each item and its own total domain score was greater than 0.40; if the correlation coefficient for each item
with its own domain score was higher than the correlation coefficient of the total scores of other domains, it had adequate discriminant validity. Exploratory factor analysis of the sample covariance matrix using the principal axis factoring method and varimax rotation was conducted to explore the factor structure. The construct validity of the MRS-TC version was established between the individual items or dimensions score of the MRS-TC version and the WHOQOL-BREF. Using WHOQOL-BREF as the gold standard, Spearman’s rank correlation between the similar domains in MRS-TC version and WHOQOL-BREF was performed. Spearman correlation coefficient was also performed between WHOQOL-BREF and utility values of WHOQOL-BREF. All data were analyzed using SPSS for Windows Version 17.0, with a two-tailed p value of 0.05 being considered statistically significant.
RESULTS From our total of 317 participants, 54.3% were postmenopausal, 28.1% perimenopausal and 17.6% premenopausal. Postmenopausal women were significantly older, with a lower level of education, and with a lower proportion of unmarried, single or working women than the other two groups (Table 1). In addition, the mean scores of individual items and four domains on the MRS were significantly different among the three groups. For quality of life, only in the physiological domain were the scores not comparable for the three groups (Table 2).
Table 1 Baseline demographic variables by menopausal status of the climacteric women. Data are given as mean standard deviation or percentage Premenopause
Perimenopause
Postmenopause
p Value
56 46.2 3.7
89 49.6 3.0
172 54.7 4.0
0.001
Level of education Junior high or below Senior high school College or above
17.9 28.6 53.6
25.8 30.3 43.8
28.7 42.7 28.7
Religion None Buddhism Other
14.3 64.3 21.4
9 77.5 13.5
6.4 81.4 12.2
Marital status Unmarried/single Married Divorced/widowed/separated
16.1 82.1 1.8
10.1 83.1 6.7
4.1 79.1 16.9
Occupation Working Homemaker None/retired
66.1 26.8 7.1
58 26.1 15.9
41.3 33.7 25
Total number of subjects Age (years)
0.007
0.121
0.001
0.003
p values are calculated for the comparison of difference amongst the different menopausal states by one-way analysis of variance followed Fisher’s least significant difference test
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Table 2 Characteristics of the different menopausal states amongst climacteric women. Data are given as mean standard deviation
Total number of subjects MRS individual items Sweating/hot flushes Heart discomfort Sleep problems Depressive mood Irritability Anxiety Exhaustion Sexual problems Bladder problems Vaginal dryness Joint & muscle discomfort MRS domain scores Psychological symptoms Somatovegetative symptoms Urogenital symptoms MRS total score WHOQOL-BREF domain scores Physiological Psychological Social Environmental
Premenopause
Perimenopause
Postmenopause
p Value
56
89
172
0.5 0.82 0.7 0.87 0.88 0.99 0.66 0.72 0.66 0.75 0.68 0.83 1.21 1.06 0.50 0.74 0.79 0.95 0.61 0.82 0.86 0.86
1.39 1.04 0.97 0.88 1.78 1.25 1.04 0.95 1.1 0.93 1.1 1.03 1.78 1.04 0.92 1.09 0.97 1.13 0.84 0.98 1.54 1.21
1.25 1.15 1.15 1.04 1.85 1.33 1.06 1.11 1.06 1.01 1.08 1.03 1.70 1.06 0.86 1.07 0.96 1.07 1.24 1.08 1.56 1.14
0.001 0.01 0.001 0.031 0.012 0.022 0.004 0.037 0.523 0.001 0.001
3.21 2.74 2.91 2.55 1.89 1.95 8.02 5.96
5.02 3.23 5.66 3.05 2.73 2.61 13.42 7.50
4.90 3.69 5.80 3.22 3.04 2.22 13.68 7.60
0.003 0.001 0.006 0.001
15.0 1.93 13.55 2.34 14.32 2.08 14.92 2.27
13.82 2.53 13.33 2.53 14.07 2.24 14.31 2.34
13.72 2.26 13.05 2.46 13.94 2.15 14.59 1.93
0.001 0.367 0.519 0.239
MRS, Menopause Rating Scale; WHOQOL-BREF, World Health Organization’s Quality of Life Instrument – Short Version; p values are calculated for the comparison of difference amongst different menopausal states by one-way analysis of variance followed by Fisher’s least significant difference test
Descriptive statistics and reliability of the MRS In the current sample, the amount of missing data was very small; four people had missing data for some items, and this Table 3
Characteristics of the 11 items in the Menopause Rating Scale questionnaire
Psychological symptoms Depressive mood Irritability Anxiety Exhaustion Somatovegetative symptoms Sweating/flushes Heart discomfort Sleep problems Joint & muscle discomfort Urogenital symptoms Sexual problems Bladder problems Vaginal dryness Total
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indicates that the MRS has good acceptability. The descriptive statistics for each question are listed in Table 3. The mean scores for the psychological, somatovegetative and urogenital subscale domains were 4.63, 5.25 and 2.75, respectively. The
Mean
Standard deviation
Item–total correlation
4.63 0.98 1 1.02 1.63 5.25 1.16 1.02 1.66 1.43 2.75 0.81 0.93 1.02 12.6
3.47 1.02 0.96 1.01 1.07 3.24 1.11 0.98 1.30 1.14 2.33 1.03 1.07 1.04 7.59
0.868 0.713 0.721 0.72 0.759 0.874 0.571 0.585 0.685 0.601 0.703 0.484 0.55 0.478
Floor effect 7.9 38.2 34.1 36.3 12 4.7 33.1 35 23 23 16.4 51.4 44.5 37.9 2.5
Ceiling effect 0.9 2.5 1.6 2.5 6 0.3 4.4 2.5 11 5.7 0.3 1.9 3.5 2.8 0.0
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Table 4 Internal consistency, convergent and discriminant validity and test–retest reliability of the Menopause Rating Scale questionnaire. Convergent validity: item correlations with own scale 0.4; discriminant validity: item correlations with own scale with other scale
Number of items Cronbach’s a
Dimension Psychological Somatovegetative Urogenital
4 4 3
0.88 0.676 0.593
Range of inter-item correlation 0.551–0.759 0.282–0.685 0.209–0.550
Test-retest reliability Convergent Discriminant validity validity 4/4 4/4 3/3
12/12 12/12 9/9
ICC
95% CI
0.925 0.856 0.83
0.908–0.94 0.822–0.885 0.79–0.865
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ICC, intraclass correlation coefficient; 95% CI, 95% confidence interval
magnitudes of the standard deviations for each question were similar. All correlations between an item with its own scale were above 0.4. In addition, substantial floor effects were observed for ‘sexual problems’ (51.4%) and ‘bladder problems’ (44.5%). The values of Cronbach’s α were 0.593 in the urogenital subscale domain, 0.676 in the somatovegetative subscale domain and 0.88 in the psychological subscale domain, respectively (Table 4). Test–retest reliability estimated by the ICC ranged from 0.83 to 0.925. It indicated a high concordance among the answers to the MRS at two different time points by the same individuals. In addition, the MRS possessed good convergent and discriminant validity (Table 4). The scores were more closely correlated with their own scale than with other scales.
Construct validity of the MRS The factor analysis did not group exactly the same as the original instrument (Table 5). The three-factor model was selected and termed as factor 1 with the primary items (i.e. loading 0.4 as a marked influence): items 3–7; factor 2 with the primary items 1, 2, 7, 9, 11; factor 3 with the primary Table 5 Construct validity from factor analysis of the three-factor model for the Menopause Rating Scale questionnaire Factor loading
Items Factor 1 Sleep problems Depressive mood Irritability Anxiety Exhaustion Factor 2 Sweating/flushes Heart discomfort Bladder problems Joint & muscle discomfort Factor 3 Sexual problems Vaginal dryness
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Variance Factor 1 Factor 2 Factor 3 explained 0.470 0.860 0.817 0.761 0.456
0.405 0.193 0.240 0.246 0.589
0.178 0.159 0.167 0.245 0.253
44.00%
0.294 0.406 0.134 0.129
0.429 0.417 0.530 0.619
0.120 0.067 0.224 0.176
11.10%
0.205 0.125
0.151 0.281
0.697 0.550
8.97%
items 8, 10. The three-factor model thus corresponded to the grouping of the MRS as psychological, somatic and urogenitalrelated symptoms. The major differences between the two versions were that the psychological domain in the MRS-TC version contained the sleeping problems and that the bladder problems belonged to the somatovegetative-related symptoms.
Criterion validity The Spearman correlation coefficients between each dimension of the MRS and those of the WHOQOL-BREF are listed in Table 6. For specific items of the MRS, the correlation was consistent with the hypothesized association with the specific item of the WHOQOL-BREF. For example, the positive correlation coefficient of item 4 of the MRS (depressive mood) and LQ26 (negative feelings) of the WHOQOL-BREF is 0.557 (p 0.001). There were also significantly negative correlation coefficients between items 3, 7 and 8 of the MRS and LQ16, LQ10 and LQ21 of the WHOQOL-BREF, respectively (p 0.001). Except for each individual item, the correlation coefficient of each domain of the MRS and the domain of the WHOQOL-BREF was significantly negatively associated.
DISCUSSION The MRS was originally composed in German and English. Although there are 25 language translations of the MRS on its official website, the traditional Chinese version has not been verified for its validity and reliability. A previous article has described the Chinese Menopause Rating Scale (CMRS); however, it was not based on the MRS but is a newly designed questionnaire about menopausal symptoms13. Moreover, compared to simplified Chinese, traditional Chinese characters are currently widely used in Taiwan, as well as in Singapore and Malaysia. Therefore, this is the first article verifying the reliability and validity of the MRS in the traditional Chinese language. Our result has shown that the MRS-TC version has good reliability, validity and high correlation with the traditional Chinese version of the WHOQOL-BREF Taiwan version. Past studies used the SF-36 to compare it with the MRS to see whether it could serve as an adequate diagnostic instrument for health-related quality of life2. However, the SF-36 assesses objective quality of life, tending to confirm specific
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Table 6 Criterion validity: using WHOQOL-BREF as the gold standard, the correlations with the Menopause Rating Scale (MRS) WHOQOL Hypothesized MRS item item association Correlation
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M4 M6 M7 M3 M11 M8
LQ26 LQ26 LQ10 LQ16 LQ3 LQ21
positive positive negative negative positive negative
0.557* 0.526* 0.498* 0.754* 0.313* 0.279*
WHOQOL-BREF Dimension
MRS dimension
Phy
Psycho
PS SS US
0.595* 0.569* 0.326*
0.574* 0.367* 0.281*
Social
Enviro
0.359* 0.428* 0.185* 0.259* 0.2* 0.194*
PS, psychological symptoms; SS, somatovegetative symptoms; US, urogenital symptoms; WHOQOL-BREF, World Health Organization’s Quality of Life Instrument – Short Version; Phy, Physical; Psycho, Psychological; Enviro, Environmental; M4, Depressive mood; M6, Anxiety; M7, Exhaustion; M3, Sleep problems; M11, Joint and muscular discomfort; M8, Sexual problems, LQ26, Negative feelings; LQ10, Enough energy; LQ16, Satisfactory sleep; LQ3, Pain hinders; LQ21, Satisfied sexual life *, significance at p 0.05
functional somatic and psychological dysfunctions, while WHOQOL-BREF refers to the subjective perception of the global quality of life including the social aspect14. In previous studies, urological complaints measured by the MRS have not only a negative impact on women’s overall quality of life but also on female sexual function6,15. ‘Sexual dysfunction’ may include a reduction in sexual desire, sexual activity and/or satisfaction and it is in the social domain in definitions of quality of life. As in previous papers, our results demonstrated that urogenital symptoms will have a negative impact on the four domains of the quality of life. Therefore, this study adopted the WHOQOL-BREF Taiwan version, which has the social domain to confirm the reliability and validity of the MRS-TC, as a more feasible way. In different races, the prevalence of menopausal symptoms is different16 and a recent study has also revealed that the results of the factor analysis for Chinese women is different from those for German women17. Past studies have revealed that the most prevalent menopausal symptoms among Chinese or Sarawakian women were physical and mental exhaustion, joint and muscle discomfort, irritability and sleep problems18,19, which are different for Caucasian women who show symptoms of flush and sweating. In addition, the incidences of neuropsychiatric symptoms are higher in Chinese women20. Thus, the results of this study’s factor analysis are slightly different from those in the original version of the MRS. The main differences in the MRS-TC are the psychological symptoms which include the sleep disorders category, but the bladder problems are classified into the somatovegetative symptoms. We believe that the main reason for the differences between Taiwanese and Caucasian women lies in the prevalence of menopausal symptoms, as well as the sleep problems, both of which have relevance for the psychological and somatic symptoms, and are more inclined to be classified in psychological problems. This is consistent with the results in the past that the psychological symptoms are related to the sleep problems and thereby affect quality of life, especially among Chinese menopausal women21,22. Therefore, we tend to categorize the problem of sleep disorders in the domain of psychological classification. More special are the symptoms
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of bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence); this study clearly categorized them in terms of the somatic and vegetative symptoms, with hot flushes, sweating, heart discomfort, joint and muscle discomfort in the same factor analysis. This result demonstrated that the bladder problems of menopausal women are not only correlated with the reproductive system and urinary tract atrophy (atrophic vaginitis) but are also associated with hormonal fluctuation-induced functional somatic syndromes23. Previous studies have shown that the urinary diseases of menopausal women such as interstitial cystitis, overactive bladder or stress urinary incontinence are very similar to the urinary complaints that were evaluated in our questionnaire24,25. Based on the literature, these diseases are also associated with somatic and vegetative symptoms6,26. That may be the reason why we obtained these results and we recommend that, when the international MRS is revised in the future, it should focus more on bladder symptoms related to atrophic vaginitis, such as frequent urination or painful urination, and repeated bladder infections. Several limitations exist in our study. First, our participants were convenient samples and not randomly selected. They were all Taiwanese natives and recruited from hospital outpatients and the community. The generalizability of the MRS and quality-of-life scores was limited. Future studies could recruit women from different settings or with different attributes. A wider range of testing could enhance the stability and generalizability of the psychometric properties of the MRS-TC version. Second, our data were collected under a cross-sectional design but the concepts being investigated (quality of life and menopausal symptoms) are known to change over time. Third, we only considered the possible association between menopause symptoms and quality of life. However, quality of life may be affected by other factors, such as social support and emotional status, which we did not investigate or for which we did not control. Appropriate menopausal assessment tools related to the quality of life allow health-care professionals to examine the progress of menopausal symptoms or treatment outcomes in time. Our study has shown that the MRS-TC version is
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Validation of Chinese version of Menopausal Rating Scale reliable and valid. This version of the questionnaire includes fewer items and is thus more user-friendly compared with the Kupperman index and other menopause quality-of-life scales. The MRS-TC version could be a helpful assessment tool for traditional Chinese-reading healthcare professionals because of its simplicity, usability, reliability, and validity. More studies are necessary to further establish its psychometric properties and to support its practical application.
ACKNOWLEDGEMENTS
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We are most grateful to all the subjects of this study for their valuable participation. The authors would like to thank
Wu et al. Jui-Hsuan Yu and Tzu-Fang Chang for their professional assistance in collecting the participants. Conflict of interest None of the authors has any confl icts of interest with other individuals or organizations that may have inappropriately influenced this work. Source of funding We would like to express our sincere gratitude for the support provided for this project in the form of grants from the Taipei Tzu Chi Hospital (Grant no. TCRDTPE-102-36). The sponsors of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. H.C.W., S.H.W., J.S.H. and S.C.H. had full access to all the data in the study and all authors had final responsibility for the decision to submit for publication.
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14. Huang IC, Wu AW, Frangakis C. Do the SF-36 and WHOQOLBREF measure the same constructs? Evidence from the Taiwan population. Qual Life Res 2006;15:15–24 15. Moore CK. The impact of urinary incontinence and its treatment on female sexual function. Curr Urol Rep 2010;11:299–303 16. Heinemann K, Ruebig A, Potthoff P, et al. The Menopause Rating Scale (MRS) scale: a methodological review. Health Qual Life Outcomes 2004;2:45 17. Hinrichsen G, Wernecke KD, Schalinski A, Borde T, David M. Menopausal symptoms in an intercultural context: a comparison between German women, Chinese women and migrant Chinese women using the Menopause Rating Scale (MRS II). Arch Gynecol Obstet 2014;290:963–71 18. Chou MF, Wun YT, Pang SM. Menopausal symptoms and the Menopausal Rating Scale among midlife Chinese women in Macau, China. Women Health 2014;54:115–26 19. Rahman SA, Zainudin SR, Mun VL. Assessment of menopausal symptoms using modified Menopause Rating Scale (MRS) among middle age women in Kuching, Sarawak, Malaysia. Asia Pac Fam Med 2010;9:5 20. Yang D, Haines CJ, Pan P, et al. Menopausal symptoms in midlife women in southern China. Climacteric 2008;11:329–36 21. Wu HC, Lai JN, Hwang JS. Quality of life and sleep quality amongst climacteric women seeking medical advice in Northern Taiwan. Sleep Med 2012;13:906–12 22. Cheng MH, Hsu CY, Wang SJ, Lee SJ, Wang PH, Fuh JL. The relationship of self-reported sleep disturbance, mood, and menopause in a community study. Menopause 2008;15:958–62 23. Warren JW, Clauw DJ, Wesselmann U, Howard FM, Gallicchio L, Morozov V. Functional somatic syndromes as risk factors for hysterectomy in early bladder pain syndrome/interstitial cystitis. J Psychosomat Res 2014;77:363–7 24. Gardella B, Porru D, Nappi RE, Dacco MD, Chiesa A, Spinillo A. Interstitial cystitis is associated with vulvodynia and sexual dysfunction – a case-control study. J Sex Med 2011;8 1726–34 25. Reid R, Abramson BL, Blake J, et al. Managing menopause. J Obstet Gynaecol Can 2014;36:830–3 26. Krieger JN, Stephens AJ, Landis JR, et al. Relationship between chronic nonurological associated somatic syndromes and symptom severity in urological chronic pelvic pain syndromes: Baseline evaluation of the MAPP Study. J Urol 2015;93:1254–62
Supplementary materials available online Supplementary Appendix 756
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ISSN: 1369-7137 (Print) 1473-0804 (Online) Journal homepage: http://www.tandfonline.com/loi/icmt20
Validation of the traditional Chinese version of the Menopausal Rating Scale with WHOQOL-BREF H-c. Wu, S-h. Wen, J-s. Hwang & S-c. Huang To cite this article: H-c. Wu, S-h. Wen, J-s. Hwang & S-c. Huang (2015) Validation of the traditional Chinese version of the Menopausal Rating Scale with WHOQOL-BREF, Climacteric, 18:5, 750-756, DOI: 10.3109/13697137.2015.1044513 To link to this article: http://dx.doi.org/10.3109/13697137.2015.1044513
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Date: 06 November 2015, At: 01:08
CLIMACTERIC 2015;18:750–756
Validation of the traditional Chinese version of the Menopausal Rating Scale with WHOQOL-BREF
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H-C. Wu*,†, S-H. Wen‡, J-S. Hwang** and S-C. Huang††,‡‡ *Division of Chinese Gynecology and Pediatrics, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City; †School of Post-baccalaureate Chinese Medicine, Tzu Chi University, Hualien; ‡Department of Public Health, College of Medicine, Tzu Chi University, Hualien; **Institute of Statistical Science, Academia Sinica, Taipei; ††Department of Obstetrics and Gynecology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City; ‡‡School of Medical, Tzu Chi University, Hualien, Taiwan Key words: MENOPAUSAL SYMPTOMS, CLIMACTERIC, QUALITY OF LIFE, MENOPAUSAL RATING SCALE – TRADITIONAL CHINESE VERSION, WHOQOL-BREF, RELIABILITY, VALIDITY
ABSTRACT Objective To assess the criterion validity, construct validity and test–retest reliability of the traditional Chinese language version of the Menopause Rating Scale (MRS-TC version). Methods This was an observational, cross-sectional study covering hospital and community samples of 317 women aged 39–62 years. Two questionnaires were administered, namely, the MRS-TC version, made up of 11 items in three dimensions, and the World Health Organization Quality of Life-BREF (WHOQOLBREF). The intraclass correlation coefficient was used to examine the test–retest reliability of the questionnaire on two separate occasions, 2 weeks apart. The internal consistency was assessed with Cronbach’s α. To evaluate criterion validity, the relationship between the individual items and dimension scores of both instruments was estimated. Pearson’s correlation was used to assess convergent and discriminant validity; construct validity was evaluated by comparing the mean scores of menopausal and non-menopausal women for each of the MRS dimensions. Results The final questionnaire comprised 11 items in three dimensions. The intra-class correlation (ICC) for the test–retest reliability ranged from 0.83 to 0.93; values of Cronbach’s α for psychological, somatic, and urogenital symptom domains were 0.88, 0.68, and 0.59, respectively. For the convergent and discriminant validity, the correlations between the individual questionnaire and the WHOQOL-BREF were significant; those with the MRS dimensions were significantly negatively associated for the physical, psychological, social and environmental domains. Conclusion The MRS-TC version using the traditional Chinese language is a reliable and valid questionnaire for assessing menopausal symptoms and global quality of life in climacteric women.
INTRODUCTION Quality of life is a subjective perception modified by the cultural context in which one lives. Assessing quality of life during the female climacteric is complex, as it involves changes occurring from physiological, psychological, sexual, social and familial points of view. Various tools have been designed to assess health-related quality of life during and after the
menopause1; one such tool is the Menopause Rating Scale (MRS) which measures the severity of menopausal symptoms. The MRS is a formally validated scale for measuring the impact of climacteric symptoms and assessing health-related quality of life of women in the menopausal transition2. The nine currently available language versions have been translated following international standards for the linguistic and cultural translation of quality-of-life scales3. However, the
Correspondence: Dr H-C. Wu, Division of Chinese Gynecology and Pediatrics, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jianguo Rd., Xindian Dist., New Taipei City 23142, Taiwan; E-mail: [email protected] ORIGINAL ARTICLE © 2015 International Menopause Society DOI: 10.3109/13697137.2015.1044513
Received 27-02-2015 Revised 20-04-2015 Accepted 20-04-2015
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Validation of Chinese version of Menopausal Rating Scale traditional Chinese version of the Menopausal Rating Scale (MRS-TC version) has to date only been translated but not validated and the contents (explanation of the 11 symptoms) of the MRS-TC version on the website are not entirely the same as in the original English version. The reason why MRS can be linked to quality of life is because it compares with the previous quality-of-life scale Short Form-36 (SF-36)2. According to the World Health Organization (WHO) definition, quality of life is an individual’s perception of their status in life, in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns4. However, if we consider the comprehensive terms of global quality of life, it not only involves the physiological and psychological, but also regarding interest in life, sexuality, maintenance of good social relationships, and a general feeling of wellness5. Estrogen deficiency in menopausal women can cause urogenital atrophy which leads to symptoms such as vaginal dryness, dyspareunia, dysuria, urge incontinence and loss of libido. The effects of these urogenital symptoms on general well-being are not only decided by the kind and severity of the symptoms but also by the individual’s psychosocial adaptation to them. In particular, the sexual problems of menopausal women are part of the social aspect of quality of life and also closely related to interpersonal relationships6. Our thesis also used the World Health Organization Quality of Life-BREF (WHOQOL-BREF), an enhanced type of general quality-oflife instrument developed by the WHOQOL Group, as compared with the MRS, and aimed to assess the criterion validity, construct validity and test–retest reliability of the MRS-TC version.
MATERIALS AND METHODS This survey was conducted among women who had perceived menopausal-related symptoms or not at the Taipei Tzu Chi Hospital or among community participants in the northern urban region of Taiwan (Republic of China). We collected data for a total of 317 participants who met the study criteria between March 2013 and December 2013 and this protocol was approved by the Institutional Ethics Committee of the Taipei Tzu Chi Hospital. All participants provided signed and informed consent.
Participants We recruited participants aged between 39 and 62 years from outpatients at gynecological clinics and from the community. Menopausal status was classified into pre-, peri- and postmenopausal. Premenopausal women were defined as having regular menstrual periods for at least 12 months prior to enrollment. Postmenopausal women were defined as having at least 1 year without menstruation and perimenopausal women were defined as those undergoing abnormal vaginal bleeding or unusual menstrual cycle lengths for the year prior
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Wu et al. to enrollment. Every participant was requested to fill out questionnaires on demographic characteristics, previous history of chronic diseases, current menstrual status, menopausal symptoms, the MRS-TC version, and the WHOQOL-BREF Taiwan version. Participants were included if they were aged around the climacteric stage and were willing to participate. Participants who had a history of cancer, psychiatric disorders, stroke, or any other disease that might significantly affect their quality of life or who had serious disability affecting their ability to communicate and answer the instruments were excluded.
Instruments MRS-TC version The translation procedure followed recognized guidelines7,8; for details of the steps, see the Supplementary Appendix to be found online at http://informahealthcare.com/doi/abs/10.3109 /13697137.2015.1044513. In the MRS-TC version questionnaire, consisting of 11 symptoms, each item was graded from 0 to 4 (0, not present; 1, mild; 2, moderate; 3, severe; 4, very severe)9. The accumulated total scale could be further divided into three subscales: (1) somatovegetative – sweating/hot flushes, heart discomfort, sleep problems and joint and muscular discomfort; (2) psychological – depressive mood, irritability, anxiety and physical and mental exhaustion; (3) urogenital – sexual problems, bladder problems and vaginal dryness. With every symptom, as in the original English version of the questionnaire, was a detailed explanation of this symptom. A total MRS-TC score was calculated as the sum of all the individual subscale scores. Participants were asked to report the menopausal symptoms shown in the MRS-TC as experienced in the previous 2 weeks.
Taiwan version of WHOQOL-BREF The Taiwan version of WHOQOL-BREF was simplified from the original WHOQOL-100 Taiwan questionnaire. The WHOQOL-BREF comprises four domains containing 24 aspects, plus two national items on overall quality of life and general health10,11. There are a total of seven items in the physical domain (pain and discomfort (LQ3), energy and fatigue (LQ10), sleep (LQ16) and rest, mobility, daily living activities, dependence on medication and working capacity), six in the psychological domain (positive feelings, thinking and concentration, self-esteem, physical image and appearance, negative feelings (LQ26) and spiritual/religious/personal beliefs), three in the social domain (personal relationships, social support and especially sexual activity (LQ21)), and eight in the environmental domain. Each item was scored on a Likert scale ranging from 1 to 5, with a higher score indicating a favorable condition after reversing the direction of several items that were originally posed in a negative way. In order to standardize the domain scores for comparison, the average score of each domain was calculated and then
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multiplied by 4, as recommended by the WHOQOL4. Thus, the domain scores ranged from 4 to 20, with a higher score indicating a better quality of life on the corresponding domain. The reliability and validity were good11,12.
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Statistical analysis We first conducted a descriptive analysis of sample characteristics and instruments. Individual items of the MRS-TC version and domains of the WHOQOL-BREF and MRS-TC version were also assessed for the different menopausal status. One-way analysis of variance followed by Fisher’s least significant difference test and the χ2 test were used to ascertain the significance of the differences between the mean values and each pair of continuous variables. The floor and ceiling effects of the MRS-TC version were assessed by calculating the proportion of subjects who scored minimum and maximum values, separately. We used the intra-class correlation coefficient (ICC) to examine the test–retest reliability of the MRS-TC version. A total of 193 participants provided repeated responses within a 2-week interval by the same evaluator. Internal consistency reliability was evaluated using Cronbach’s α coefficient. Each value of the coefficient that was greater than 0.7 indicated satisfactory agreements. Pearson’s correlation was applied to evaluate convergent and discriminant validity. It had adequate convergent validity when the correlation coefficient between the score for each item and its own total domain score was greater than 0.40; if the correlation coefficient for each item
with its own domain score was higher than the correlation coefficient of the total scores of other domains, it had adequate discriminant validity. Exploratory factor analysis of the sample covariance matrix using the principal axis factoring method and varimax rotation was conducted to explore the factor structure. The construct validity of the MRS-TC version was established between the individual items or dimensions score of the MRS-TC version and the WHOQOL-BREF. Using WHOQOL-BREF as the gold standard, Spearman’s rank correlation between the similar domains in MRS-TC version and WHOQOL-BREF was performed. Spearman correlation coefficient was also performed between WHOQOL-BREF and utility values of WHOQOL-BREF. All data were analyzed using SPSS for Windows Version 17.0, with a two-tailed p value of 0.05 being considered statistically significant.
RESULTS From our total of 317 participants, 54.3% were postmenopausal, 28.1% perimenopausal and 17.6% premenopausal. Postmenopausal women were significantly older, with a lower level of education, and with a lower proportion of unmarried, single or working women than the other two groups (Table 1). In addition, the mean scores of individual items and four domains on the MRS were significantly different among the three groups. For quality of life, only in the physiological domain were the scores not comparable for the three groups (Table 2).
Table 1 Baseline demographic variables by menopausal status of the climacteric women. Data are given as mean standard deviation or percentage Premenopause
Perimenopause
Postmenopause
p Value
56 46.2 3.7
89 49.6 3.0
172 54.7 4.0
0.001
Level of education Junior high or below Senior high school College or above
17.9 28.6 53.6
25.8 30.3 43.8
28.7 42.7 28.7
Religion None Buddhism Other
14.3 64.3 21.4
9 77.5 13.5
6.4 81.4 12.2
Marital status Unmarried/single Married Divorced/widowed/separated
16.1 82.1 1.8
10.1 83.1 6.7
4.1 79.1 16.9
Occupation Working Homemaker None/retired
66.1 26.8 7.1
58 26.1 15.9
41.3 33.7 25
Total number of subjects Age (years)
0.007
0.121
0.001
0.003
p values are calculated for the comparison of difference amongst the different menopausal states by one-way analysis of variance followed Fisher’s least significant difference test
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Table 2 Characteristics of the different menopausal states amongst climacteric women. Data are given as mean standard deviation
Total number of subjects MRS individual items Sweating/hot flushes Heart discomfort Sleep problems Depressive mood Irritability Anxiety Exhaustion Sexual problems Bladder problems Vaginal dryness Joint & muscle discomfort MRS domain scores Psychological symptoms Somatovegetative symptoms Urogenital symptoms MRS total score WHOQOL-BREF domain scores Physiological Psychological Social Environmental
Premenopause
Perimenopause
Postmenopause
p Value
56
89
172
0.5 0.82 0.7 0.87 0.88 0.99 0.66 0.72 0.66 0.75 0.68 0.83 1.21 1.06 0.50 0.74 0.79 0.95 0.61 0.82 0.86 0.86
1.39 1.04 0.97 0.88 1.78 1.25 1.04 0.95 1.1 0.93 1.1 1.03 1.78 1.04 0.92 1.09 0.97 1.13 0.84 0.98 1.54 1.21
1.25 1.15 1.15 1.04 1.85 1.33 1.06 1.11 1.06 1.01 1.08 1.03 1.70 1.06 0.86 1.07 0.96 1.07 1.24 1.08 1.56 1.14
0.001 0.01 0.001 0.031 0.012 0.022 0.004 0.037 0.523 0.001 0.001
3.21 2.74 2.91 2.55 1.89 1.95 8.02 5.96
5.02 3.23 5.66 3.05 2.73 2.61 13.42 7.50
4.90 3.69 5.80 3.22 3.04 2.22 13.68 7.60
0.003 0.001 0.006 0.001
15.0 1.93 13.55 2.34 14.32 2.08 14.92 2.27
13.82 2.53 13.33 2.53 14.07 2.24 14.31 2.34
13.72 2.26 13.05 2.46 13.94 2.15 14.59 1.93
0.001 0.367 0.519 0.239
MRS, Menopause Rating Scale; WHOQOL-BREF, World Health Organization’s Quality of Life Instrument – Short Version; p values are calculated for the comparison of difference amongst different menopausal states by one-way analysis of variance followed by Fisher’s least significant difference test
Descriptive statistics and reliability of the MRS In the current sample, the amount of missing data was very small; four people had missing data for some items, and this Table 3
Characteristics of the 11 items in the Menopause Rating Scale questionnaire
Psychological symptoms Depressive mood Irritability Anxiety Exhaustion Somatovegetative symptoms Sweating/flushes Heart discomfort Sleep problems Joint & muscle discomfort Urogenital symptoms Sexual problems Bladder problems Vaginal dryness Total
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indicates that the MRS has good acceptability. The descriptive statistics for each question are listed in Table 3. The mean scores for the psychological, somatovegetative and urogenital subscale domains were 4.63, 5.25 and 2.75, respectively. The
Mean
Standard deviation
Item–total correlation
4.63 0.98 1 1.02 1.63 5.25 1.16 1.02 1.66 1.43 2.75 0.81 0.93 1.02 12.6
3.47 1.02 0.96 1.01 1.07 3.24 1.11 0.98 1.30 1.14 2.33 1.03 1.07 1.04 7.59
0.868 0.713 0.721 0.72 0.759 0.874 0.571 0.585 0.685 0.601 0.703 0.484 0.55 0.478
Floor effect 7.9 38.2 34.1 36.3 12 4.7 33.1 35 23 23 16.4 51.4 44.5 37.9 2.5
Ceiling effect 0.9 2.5 1.6 2.5 6 0.3 4.4 2.5 11 5.7 0.3 1.9 3.5 2.8 0.0
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Table 4 Internal consistency, convergent and discriminant validity and test–retest reliability of the Menopause Rating Scale questionnaire. Convergent validity: item correlations with own scale 0.4; discriminant validity: item correlations with own scale with other scale
Number of items Cronbach’s a
Dimension Psychological Somatovegetative Urogenital
4 4 3
0.88 0.676 0.593
Range of inter-item correlation 0.551–0.759 0.282–0.685 0.209–0.550
Test-retest reliability Convergent Discriminant validity validity 4/4 4/4 3/3
12/12 12/12 9/9
ICC
95% CI
0.925 0.856 0.83
0.908–0.94 0.822–0.885 0.79–0.865
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ICC, intraclass correlation coefficient; 95% CI, 95% confidence interval
magnitudes of the standard deviations for each question were similar. All correlations between an item with its own scale were above 0.4. In addition, substantial floor effects were observed for ‘sexual problems’ (51.4%) and ‘bladder problems’ (44.5%). The values of Cronbach’s α were 0.593 in the urogenital subscale domain, 0.676 in the somatovegetative subscale domain and 0.88 in the psychological subscale domain, respectively (Table 4). Test–retest reliability estimated by the ICC ranged from 0.83 to 0.925. It indicated a high concordance among the answers to the MRS at two different time points by the same individuals. In addition, the MRS possessed good convergent and discriminant validity (Table 4). The scores were more closely correlated with their own scale than with other scales.
Construct validity of the MRS The factor analysis did not group exactly the same as the original instrument (Table 5). The three-factor model was selected and termed as factor 1 with the primary items (i.e. loading 0.4 as a marked influence): items 3–7; factor 2 with the primary items 1, 2, 7, 9, 11; factor 3 with the primary Table 5 Construct validity from factor analysis of the three-factor model for the Menopause Rating Scale questionnaire Factor loading
Items Factor 1 Sleep problems Depressive mood Irritability Anxiety Exhaustion Factor 2 Sweating/flushes Heart discomfort Bladder problems Joint & muscle discomfort Factor 3 Sexual problems Vaginal dryness
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Variance Factor 1 Factor 2 Factor 3 explained 0.470 0.860 0.817 0.761 0.456
0.405 0.193 0.240 0.246 0.589
0.178 0.159 0.167 0.245 0.253
44.00%
0.294 0.406 0.134 0.129
0.429 0.417 0.530 0.619
0.120 0.067 0.224 0.176
11.10%
0.205 0.125
0.151 0.281
0.697 0.550
8.97%
items 8, 10. The three-factor model thus corresponded to the grouping of the MRS as psychological, somatic and urogenitalrelated symptoms. The major differences between the two versions were that the psychological domain in the MRS-TC version contained the sleeping problems and that the bladder problems belonged to the somatovegetative-related symptoms.
Criterion validity The Spearman correlation coefficients between each dimension of the MRS and those of the WHOQOL-BREF are listed in Table 6. For specific items of the MRS, the correlation was consistent with the hypothesized association with the specific item of the WHOQOL-BREF. For example, the positive correlation coefficient of item 4 of the MRS (depressive mood) and LQ26 (negative feelings) of the WHOQOL-BREF is 0.557 (p 0.001). There were also significantly negative correlation coefficients between items 3, 7 and 8 of the MRS and LQ16, LQ10 and LQ21 of the WHOQOL-BREF, respectively (p 0.001). Except for each individual item, the correlation coefficient of each domain of the MRS and the domain of the WHOQOL-BREF was significantly negatively associated.
DISCUSSION The MRS was originally composed in German and English. Although there are 25 language translations of the MRS on its official website, the traditional Chinese version has not been verified for its validity and reliability. A previous article has described the Chinese Menopause Rating Scale (CMRS); however, it was not based on the MRS but is a newly designed questionnaire about menopausal symptoms13. Moreover, compared to simplified Chinese, traditional Chinese characters are currently widely used in Taiwan, as well as in Singapore and Malaysia. Therefore, this is the first article verifying the reliability and validity of the MRS in the traditional Chinese language. Our result has shown that the MRS-TC version has good reliability, validity and high correlation with the traditional Chinese version of the WHOQOL-BREF Taiwan version. Past studies used the SF-36 to compare it with the MRS to see whether it could serve as an adequate diagnostic instrument for health-related quality of life2. However, the SF-36 assesses objective quality of life, tending to confirm specific
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Table 6 Criterion validity: using WHOQOL-BREF as the gold standard, the correlations with the Menopause Rating Scale (MRS) WHOQOL Hypothesized MRS item item association Correlation
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M4 M6 M7 M3 M11 M8
LQ26 LQ26 LQ10 LQ16 LQ3 LQ21
positive positive negative negative positive negative
0.557* 0.526* 0.498* 0.754* 0.313* 0.279*
WHOQOL-BREF Dimension
MRS dimension
Phy
Psycho
PS SS US
0.595* 0.569* 0.326*
0.574* 0.367* 0.281*
Social
Enviro
0.359* 0.428* 0.185* 0.259* 0.2* 0.194*
PS, psychological symptoms; SS, somatovegetative symptoms; US, urogenital symptoms; WHOQOL-BREF, World Health Organization’s Quality of Life Instrument – Short Version; Phy, Physical; Psycho, Psychological; Enviro, Environmental; M4, Depressive mood; M6, Anxiety; M7, Exhaustion; M3, Sleep problems; M11, Joint and muscular discomfort; M8, Sexual problems, LQ26, Negative feelings; LQ10, Enough energy; LQ16, Satisfactory sleep; LQ3, Pain hinders; LQ21, Satisfied sexual life *, significance at p 0.05
functional somatic and psychological dysfunctions, while WHOQOL-BREF refers to the subjective perception of the global quality of life including the social aspect14. In previous studies, urological complaints measured by the MRS have not only a negative impact on women’s overall quality of life but also on female sexual function6,15. ‘Sexual dysfunction’ may include a reduction in sexual desire, sexual activity and/or satisfaction and it is in the social domain in definitions of quality of life. As in previous papers, our results demonstrated that urogenital symptoms will have a negative impact on the four domains of the quality of life. Therefore, this study adopted the WHOQOL-BREF Taiwan version, which has the social domain to confirm the reliability and validity of the MRS-TC, as a more feasible way. In different races, the prevalence of menopausal symptoms is different16 and a recent study has also revealed that the results of the factor analysis for Chinese women is different from those for German women17. Past studies have revealed that the most prevalent menopausal symptoms among Chinese or Sarawakian women were physical and mental exhaustion, joint and muscle discomfort, irritability and sleep problems18,19, which are different for Caucasian women who show symptoms of flush and sweating. In addition, the incidences of neuropsychiatric symptoms are higher in Chinese women20. Thus, the results of this study’s factor analysis are slightly different from those in the original version of the MRS. The main differences in the MRS-TC are the psychological symptoms which include the sleep disorders category, but the bladder problems are classified into the somatovegetative symptoms. We believe that the main reason for the differences between Taiwanese and Caucasian women lies in the prevalence of menopausal symptoms, as well as the sleep problems, both of which have relevance for the psychological and somatic symptoms, and are more inclined to be classified in psychological problems. This is consistent with the results in the past that the psychological symptoms are related to the sleep problems and thereby affect quality of life, especially among Chinese menopausal women21,22. Therefore, we tend to categorize the problem of sleep disorders in the domain of psychological classification. More special are the symptoms
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of bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence); this study clearly categorized them in terms of the somatic and vegetative symptoms, with hot flushes, sweating, heart discomfort, joint and muscle discomfort in the same factor analysis. This result demonstrated that the bladder problems of menopausal women are not only correlated with the reproductive system and urinary tract atrophy (atrophic vaginitis) but are also associated with hormonal fluctuation-induced functional somatic syndromes23. Previous studies have shown that the urinary diseases of menopausal women such as interstitial cystitis, overactive bladder or stress urinary incontinence are very similar to the urinary complaints that were evaluated in our questionnaire24,25. Based on the literature, these diseases are also associated with somatic and vegetative symptoms6,26. That may be the reason why we obtained these results and we recommend that, when the international MRS is revised in the future, it should focus more on bladder symptoms related to atrophic vaginitis, such as frequent urination or painful urination, and repeated bladder infections. Several limitations exist in our study. First, our participants were convenient samples and not randomly selected. They were all Taiwanese natives and recruited from hospital outpatients and the community. The generalizability of the MRS and quality-of-life scores was limited. Future studies could recruit women from different settings or with different attributes. A wider range of testing could enhance the stability and generalizability of the psychometric properties of the MRS-TC version. Second, our data were collected under a cross-sectional design but the concepts being investigated (quality of life and menopausal symptoms) are known to change over time. Third, we only considered the possible association between menopause symptoms and quality of life. However, quality of life may be affected by other factors, such as social support and emotional status, which we did not investigate or for which we did not control. Appropriate menopausal assessment tools related to the quality of life allow health-care professionals to examine the progress of menopausal symptoms or treatment outcomes in time. Our study has shown that the MRS-TC version is
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Validation of Chinese version of Menopausal Rating Scale reliable and valid. This version of the questionnaire includes fewer items and is thus more user-friendly compared with the Kupperman index and other menopause quality-of-life scales. The MRS-TC version could be a helpful assessment tool for traditional Chinese-reading healthcare professionals because of its simplicity, usability, reliability, and validity. More studies are necessary to further establish its psychometric properties and to support its practical application.
ACKNOWLEDGEMENTS
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We are most grateful to all the subjects of this study for their valuable participation. The authors would like to thank
Wu et al. Jui-Hsuan Yu and Tzu-Fang Chang for their professional assistance in collecting the participants. Conflict of interest None of the authors has any confl icts of interest with other individuals or organizations that may have inappropriately influenced this work. Source of funding We would like to express our sincere gratitude for the support provided for this project in the form of grants from the Taipei Tzu Chi Hospital (Grant no. TCRDTPE-102-36). The sponsors of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. H.C.W., S.H.W., J.S.H. and S.C.H. had full access to all the data in the study and all authors had final responsibility for the decision to submit for publication.
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Supplementary materials available online Supplementary Appendix 756
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