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J Epilepsy Res > Volume 6(2); 2016 > Article
Asadollahi, Saberi, Havasi, and Kaveh: Psychometric Properties of the Persian Version of the Quality of Life in Epilepsy Inventory in the Later Life

Abstract

Background and Purpose

The reports indicate on the incidence of seizure disorder about 1.5 per cent of the normal elderly population. The Quality of Life in Epilepsy Inventory (QOLIE-31) has been pervasive simple tool to screen seizure in the busy neurophysiological settings and monitoring. It was constructed as self-administered tool in two formats, 89 and 31-items. To the reliability and validity of the QOLIE-31 across older adults in the southwest Iran and discuss its role in the detection of health-related quality of elderly patients with epilepsy.

Methods

About 73 older adults (mean age = 66.3 ± 1.71) were sampled from the eight hospitals and caring centres. They replied to the QOLIE-31. External and criterion validity was calculated by correlation to the SF-36 questionnaire, to check and validate the epilepsy specific dimensions. The QOLIE-31 includes seven subscales: overall quality of life, seizure worry, emotional well-being, energy/fatigue, cognitive, medication effects, and social function.

Results

There was significant difference within sample groups regarding main variables (p < 0.05). The coefficients of Cronbach’s alpha (α= 0.76), convergent validity (0.81), divergent validity (−0.21), external validity with overall score of SF-36 (0.87), and criterion validity (0.78) were estimated, which were significant at p < 0.01. The exploratory factor analysis demonstrated that the QOLIE-31 is organized into six factors, which clarifies 92 per cent of the scale’s variance. Second-order confirmatory factor analysis pointed out that the factor is well matched up onto a principal factor. Consequently, the 6-factors model was well appropriate for the data by the fit index techniques for adjusting the scale (AGFI = 0.94, GFI = 0.96, RMSEA = 0.003, IFI = 0.90, NFI = 0.95, CFI = 0.95).

Conclusions

The results pointed to the well-adjusted reliability and psychometric properties of the QOLIE-31 and its usefulness for the relevant studies as well.

Introduction

Epilepsy is a condition of decreasing neuronal system that usually begins to occur at any years of age. It is the most common neurological disorder-affecting people of all ages and is important to understand that epilepsy is a physical rather than mental disorder. There may be a problem by refusing to even talk about the symptoms. There are many different types of seizure, which are divided into two main groups i.e. generalized seizures, which occur when the disturbance is spread across all of the brain, and the second is partial seizures when only part of the brain is affected.1,2 Epilepsy can affect anyone at any time of life. It is more usually diagnosed in people under the age of 20 or those aged over 60. Most seizures are short-lived and need no medical attention.37 Over ten thousand articles on seizure (or epilepsy) for juveniles and youths can be found, but relatively less has been conducted on the older adults’ equivalent.810 The ratio of published studies of seizure within young adults to older adults is approximately 1:100.4,1113 Attaining knowledge regarding epilepsy among elderly people will help the care-givers and gerontologists to achieve the ultimate goal of a dignified healthy ageing,1417 and maintain the highest quality of life.8,1821 Thus, it is adding life to years and not simply years to life.22,23 While ignorance about elderly seizure, having an instrument turns out to be a necessity.9,2427 It is helpful even in the clinical treatment as well.28 The study was investigated to the standards of quality of life in epilepsy inventory in the later life, the shortened version (QOLIE-31) (1993, 2005) within older adults to introduce a relevant criterion. The measurement of external validity had contained correlating relation of the SF-36 and QOLIE-31 Inventories, to check the properties of the epilepsy specific dimensions.

Methods

About 73 men and women with age range of 57 to 91 and with the mean age of 66.3 ± 1.71 were sampled with the cluster-ratio sampling method from the eight medical centres and hospitals of Khuzistan province in the southwest Iran. The aged samples replied to the 31 items of QOLIE-31. The QOLIE-31 questionnaire mainly consists of a 31-item disability/symptom scale regarding epilepsy that was investigated by authors and literature reviews.2,4,7,12,13,20,22,24,27,29 It was developed in three version i.e. 89, 31, and 10 items. The 31 items is most common used version of QOLIE-31. Each item in the scale has several responses i.e. six response options from 1 = all of the time to 6 = none of the time severe (Item No: 2–12), four response options from 1 = very fearful to 4 = not fearful at all (Item No: 15–24). In addition, other formats have five response options from 1=not at all bothersome to 5=extremely bothersome (Item No: 25–30), and three closed-form and shaped items. If the 31 items are completed, a scale score ranging from 25 (no symptoms) to 125 (most severe symptoms), can be calculated. The QOLIE-31 contains 31 items on the following domains: overall quality of life (OQ), emotional wellbeing (EW), energy-fatigue (EF), cognitive functioning (CF), medication effects (ME), seizure worry (SW), and Social functioning (SF).

External and Criterion Validity

It was estimated by the correlations of overall scores of QOLIE-31 and its domains to other similar instrument like SF-36. The Pearson’s correlation coefficients was used to measure the relationship between scales of QOLIE-31 and SF-36. Strong correlations were expected between domains and scales with the same content. The SF-36 range from 0 to 100, with 100 representing the highest level of functioning possible in the QoL.

Translating the Instrument

Psychometric properties of the QOLIE-31 was evaluated in several divergent backgrounds and cultural groups i.e. Spanish, German, Thai, Norwegian, French, Italian, Portuguese, Serbian, Bulgarian, and Czech context.2,19,3035 The study translated it into Persian from its English version4,12 by three instructors and an English language expert. The four translated versions were compared by the authors, and the researchers developed a common Persian text from them. Afterwards, the Persian version of the QOLIE-31 was translated back into English by an English language expert who had not seen the original English text and by a linguist. The English statements of the questionnaire that had been translated from Persian into English were compared with the original version, and any necessary revisions were made as well.

Setting and Participants

From the eight medical centres and hospitals of Khuzistan province in the southwest Iran, about 80 aged men who had been constant patients at the centers responded to the Iranian version of the QOLIE-31. Of the 80 responders, 73 had responded to all of the 31 items used in the inventory and included in the analysis. The mean age of the samples was 66.3 ± 1.71 (range 57–91) years.

Results

About 73 elderly patients were the samples of the study, 45 men (79.5%) and 28 women (20.4%) with a mean age of 68.9 years of old (standard deviation [SD] = 7.77). All of patients were replied to both inventories of study, QOLIE-31 and SF-36. The demographic characteristics are shown in Table 1 and clinical characteristics in Table 2. The comparing QOLIE-31 overall score made between elderly males and females regarding their health status, education, occupation, marital status, and other demographic characteristics, type of epilepsy, etiology, seizure type, seizure severity, and antiepileptic drugs, revealed statistically significant difference within samples.

Internal Consistency

The coefficients of Cronbach’s alpha (α = 0.89), convergent validity (0.81), divergent validity (−0.21), and criterion validity (0.78) were estimated, which were significant at ρ < 0.01. The discriminative power in the QOLIE-31 of sub-scales with overall score using Kolmogorov-Smirnov and Shapiro-Wilk tests of normality demonstrated an almost normal distribution (Table 3). Mean overall score was 52.5 (CI = 38–67) and SD = 19.42. Discriminative power testing showed that domains showed an almost normal distribution (Table 3).
Regarding criterion validity, Pearson’s correlation coefficients were significant and appropriate for all sub-domains of QOLIE-31 and SF-36. This finding could suggest some specificity of these domains. Table 4 summarizes the appropriate correlation of the two questionnaires’ subscales.

Contrast Validity

The exploratory factor analysis demonstrated that the 31-items of QOLIE-31 for aged samples are organized into seven factors (factor 1: seizure worry, factor 2: overall QoL, factor 3: emotional wellbeing, & factor 4: energy/fatigue, factor 5: cognitive, factor 6: social functioning, and factor 7: medication effects) which clarify 94 percent of the scale’s variance. Second-order confirmatory factor analysis pointed out that the factors were well matched up onto a principal factor. According to the Table 5, the rotated factor matrix pattern of Varimax for the QOLIE-31’s subscale questions was considered. Those questions with factor loadings above 0.80 were selected.
There are covariate between some items i.e. item No. 14 between factors No. 2 and 3, item No. 9 between factors No. 3 and 5, item No. 26 between factors No. 5 and 7 in Persian version of QOLIE-31. It may acclaim that covariate item of the factors like overall QoL, emotional wellbeing, cognitive, and medication effects could be reconstructed as well.
Consequently, the 7-factor model was appropriate for the data and the fit index techniques for adjusting the scale. The indexes of the model’s goodness of fit refer to the integrity of the 7-factor model with data. The χ2 to degrees of freedom is less than 2 in efficient models. It is closer to zero and will be closer. The root mean square error of approximation (RMSEA) and standardized root mean residual (SRMR) must be less than 0.05 that indicate to good models. The model pointed out the goodness of fit of the model in the study (AGFI = 0.94, GFI = 0.96, RMSEA = 0.003, IFI = 0.90, NFI = 0.95, CFI = 0.95).
As closer measure to 1 in the normed fit index (NFI), the comparative fit index (CFI), goodness-of-fit statistic (GFI), the incremental fit index (IFI), and the adjusted goodness of fit index (AGFI), they refer to the goodness and fit of model. They were more than 0.90 (Table 6).

Discussion

The aim of the study is to look for the relevant instrument regarding common symptoms of an nervous-related issue called Epilepsy within aged people in the Iranian social context, even the issue still is challengeable.3,4,9,13,20,21,26 So, the quality of life in epilepsy questionnaire (QOLIE-31, 1993 & 2005) was used and evaluated. The results stated to the well-adjusted psychometric properties, discriminative statistic, reliability, and validity of QOLIE-31 and usefulness of it in the relevant studies too. Regarding the external validity, correlation coefficients were significant and appropriate all sub-domains of QOLIE-31 with SF-36 as well. Therefore, future researchers should not limit themselves to the western scales,7,21 but should also consider specific cultural factors.
Persian-language version of QOLIE-31 illustrated appropriate satisfactory psychometric statistics, good reliability, high internal consistency, valuable discriminative characteristics. It has applicable level in the conceptual similarity to the original English-language version. Comparing the results of the study to other similar research indicated to adapting the measures to English, Italian, Bulgarian, Serbian, and French version of QOLIE-31.2,19,3035
Regarding the findings of the study, the QOLIE-31 is appropriate for validity and reliability in the aged community of the Iranian society and it can be employed to measure quality of life of aged patient with seizure symptoms. Additionally, it is applicable by gerontologists, neuropsychologists, neurophysiologists, geronto-psychiatrics, and neurologists for the future studies as well as to the geriatrics in their diagnostics. Regarding the divergent background, it is first time suggested that in the future studies, the gender-related symptoms of epilepsy and moderating the seizure experience within minorities groups, which are compatible with communities like Iran’s native culture, be conducted and evaluated as well.

Acknowledgements

We wish to thank colleagues and the anonymous referees for their valuable comments.

Notes

Authors’ Contributions: AH contributed to the design, performed the interviews, AHH interpreted data from the interviews. LFS has contributed to the design, interpretation, and discussion. AN analysed the data and AA wrote the draft and has revised the content, scientific writing. All authors have approved the final manuscript as well.

Table 1
Frequency distribution and comparison of seniors’ demographic and background profiles by gender (n = 73, p ≤ 0.05)
Categories Sub Items n % Male Female χ2/ρ-value
Gender Male 45 79.56 - - 1.105/ 0.000
Female 28 20.44 - -
Age (Mean = 66.3, SD = 1.71) 60–70 (young old) 36 49.32 20 16 2.125/0.000
71–80 (middle old) 21 28.77 13 8
≥ 81 (old old) 16 21.92 8 8
Ethnicity Persian 30 41.10 15 15 4.142/0.000
Arab 22 30.14 18 4
Lor 21 28.77 16 5
Educational status No formal school 52 71.23 21 31 12.5/ 0.000
Only reading 17 23.29 10 7
Primary 2 2.74 2 0
Middle school 1 1.37 1 0
High school 0 0.00 0 0
Graduated 1 1.37 1 0
Marital status Divorced 1 1.37 1 0 32.4/0.000
Widowed 21 28.77 7 14
Separated 0 0.00 0 0
Married 43 58.90 31 12
Never married 2 2.74 0 2
Living with other 6 8.22 0 6
Length of married time (Mean = 29.3, SD = 3.27) [national range: Mean = 25.1 and SD = 3.1] ≤ 10 year 9 12.33 9 0 21.61/ 0.000
11–20 year 15 20.55 10 5
21–30 year 47 64.38 33 14
≥ 31 year 2 2.74 0 2
Family members (Mean = 5.7, SD = 1.34) ≤ 5 persons 41 56.16 20 21 23.8/ 0.005
≥ 6 persons 32 43.84 15 17
Economic support and pensioning Nothing 52 71.23 12 40 21.3/0.000
Public 19 26.03 10 9
Private 2 2.74 2 0
Range of financial support upon urban poverty ratio* (Mean = 936439.79, SD = 1.48) Nothing 48 65.75 36 12 23.5/0.000
≤ 990,000 10 13.70 5 5
1000000–4500000 8 10.96 8 0
4510000–7990000 5 6.85 5 0
≥ 8000000 2 2.74 2 0
Municipal zones 1= Middle Class 12 16.44 6 6 34.01/0.059
2= Developed 8 10.96 5 3
3= Developed 8 10.96 3 5
4= Undeveloped 13 17.81 10 3
5= Undeveloped 7 9.59 4 3
6= Middle Class 4 5.48 2 2
7= Middle Class 9 12.33 5 4
8= Undeveloped 12 16.44 5 7

* Based on Iranian Rials currency and 1 US$= 29060 IR Rials in 2014.

They are economically divided into three parts i.e. poor and undeveloped = 29.6% (zone 4, 5, & 8), middle class= 48.6% (zone 1, 6, & 7), wealthy and developed = 21.8% (zone 2 & 3) regarding income of citizens and urban facilities based on Provincial Report of KSCC (2011).

Table 2
Frequency distribution and comparison of seniors’ clinical characteristics profiles by gender (n = 73, p ≤ 0.05)
Categories Sub Items n % Male Female χ2/ρ-value
Type of epilepsy Tonic-clonic 31 42.47 17 14 21.01/0.009
Partial 20 27.4 4 16
Absence 13 17.81 10 3
Others 9 12.33 6 3
Etiology Idiopathic 22 30.14 16 6 32.00/0.001
Symptomatic 38 52.06 15 23
Cryptogenic 13 17.81 11 2
Seizure type Absence 7 9.59 3 4 13.8/0.001
Myoclonic 11 15.07 5 6
Primarily generalized tonic-clonic 14 19.18 6 8
Simple partial 18 24.66 11 7
Complex partial 9 12.33 8 1
Secondarily generalized tonic-clonic 14 19.18 9 5
Seizure severity Controlled 18 24.66 10 8 22.08/0.000
Low 13 17.81 9 4
Moderate 18 24.66 5 13
High 10 13.70 7 3
Very High 14 19.18 10 4
Antiepileptic drugs Therapy withdrawn 38 52.06 17 21 12.00/0.010
Monotherapy 24 32.88 11 13
Polytherapy 11 15.07 8 3
Duration  Total = Mean: 17.02 years, Range: 2–63 year 14.04/0.000
 Male = Mean: 19.11 years, Range: 1–63 years
 Female = Mean: 16.13 years, Range: 3–56 years
Table 3
Descriptive statistics and discriminative power in the QOLIE-31 of sub-scales with overall score
Domains (Item Number) No. of items Mean (95%CI)* Median SD Cronbach’s α KS SV df ρ-value
Seizure worry (11,21,22,23,25) 5 54.5 (28–81) 53 26.04 0.83 0.094 0.089 72 0.0001
Overall QoL (1,14) 2 53.2 (21–72) 47 28.01 0.85 0.074 0.087 73 0.0001
Emotional well-being (3,4,5, 7,9) 5 58.7 (39.2–87.2) 65 21.01 0.79 0.149 0.152 72 0.0001
Energy/fatigue (2,6,8,10) 4 20.0 (11.25–28.75) 53 19.21 0.73 0.092 0.071 72 0.0001
Cognitive functioning (12,15,16,17,18,26) 6 50.7 (32.8–68.6) 47 13.30 0.81 0.073 0.088 73 0.0002
Medication effects (24,29,30) 3 42.28 (13.86–70.7) 33 22.82 0.87 0.147 0.133 72 0.0001
Social functioning (13,19,20,27,28) 5 59.84 (37.42–82.26) 54 25.33 0.88 0.148 0.145 72 0.0001
Total score 30 52.5 (38–67) 53 19.42 0.89 0.083 0.091 71 0.0001

* The score range = 0–100. n = 73.

Kolmogorov-Smirnov test of normality.

Shapiro-Wilk test of normality.

Table 4
Pearson correlations between QOLIE-31 and SF-36 sub-domains (p < 0.05)
SF-36/QOLIE-31 SW OQoL EWB E/F CF ME SF TQoLIE
BP 0.501 0.474 0.577 0.501 0.106 0.543 0.405 0.675
GH 0.479 0.438 0.571 0.469 0.436 0.589 0.416 0.723
MH 0.498 0.585 0.484 0.349 0.514 0.444 0.580 0.689
PF 0.478 0.458 0.371 0.435 0.446 0.433 0.414 0.771
RE 0.548 0.324 0.266 0.441 0.438 0.437 0.497 0.623
RP 0.578 0.458 0.371 0.435 0.446 0.533 0.514 0.771
SF 0.501 0.474 0.577 0.601 0.306 0.543 0.505 0.699
VT 0.479 0.438 0.471 0.569 0.486 0.389 0.516 0.723
TSF-36 0.378 0.458 0.571 0.535 0.446 0.433 0.414 0.871

BP, bodily pain; GH, general health; MH, mental health; PF, physical functioning; RE, role emotional; RP, role physical; SF, social functioning; VT, vitality; SW, seizure worry; OQoL, overall quality of life; EWB, emotional well-being; E/F, energy/fatigue; CF, cognitive functioning; ME, medication effects; SF, social functioning; TQoLIE, total scores of overall QoLIE-31, TSF, total scores of SF-36.

Table 5
Varimax rotated factors matrix of the QOLIE-31 (only factor loadings ≥5)
Domain No. of Item Mean SD Components

Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6 Factor 7
SW 11 0.40 0.49 0.83
SW 21 0.29 0.46 0.84
SW 22 0.31 0.47 0.87
SW 23 0.31 0.47 0.83
SW 25 0.16 0.47 0.90
OQoL 1 0.29 0.37 0.88
OQoL 14 0.40 0.46 0.89 0.80
EWB 3 0.24 0.40 0.81
EWB 4 0.33 0.49 0.82
EWB 5 0.36 0.43 0.93
EWB 7 0.09 0.47 0.80
EWB 9 0.33 0.48 0.89 0.80
E/F 2 0.24 0.24 0.95
E/F 6 0.28 0.47 0.88
E/F 8 0.17 0.43 0.86
E/F 10 0.09 0.38 0.82
CF 12 0.09 0.28 0.83
CF 15 0.40 0.46 0.94
CF 16 0.24 0.40 0.90
CF 18 0.33 0.49 0.91
CF 26 0.36 0.43 0.88 0.80
SF 13 0.09 0.47 0.80
SF 19 0.33 0.48 0.80
SF 20 0.24 0.24 0.81
SF 27 0.28 0.47 0.83
SF 28 0.32 0.47 0.87
ME 24 0.27 0.38 0.94
ME 29 0.31 0.46 0.92
ME 30 0.33 0.31 0.91

SW, seizure worry; OQoL, overall quality of life; EWB, emotional well-being; E/F, energy/fatigue; CF, cognitive function; ME, medication effects; SF, social function.

Table 6
The goodness of fit indexes model
Indexes χ2 df χ2/df AGFI GFI RMSEA IFI NFI CFI
Value 131.81 72 1.83 0.94 0.96 0.003 0.90 0.95 0.95

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