Academic journal article Health and Social Work

Assessment and the Ubiquity of Culture: Threats to Validity in Measures of Health-Related Quality of Life

Academic journal article Health and Social Work

Assessment and the Ubiquity of Culture: Threats to Validity in Measures of Health-Related Quality of Life

Article excerpt

In a philosophical discussion about power and subjugation, the French philosopher, Michel Foucault (1980) wrote that research is an apparatus of control, and thus power, in health care, this control and power will determine who gets services, at what level, and in what time frame. The resistance of competing research interests to relinquish control and power accounts for tensions between biological and psychosocial approaches to measuring patient outcomes. As an example, consider how, until recently, health outcomes were assessed by readily measured biological phenomena. It took an act of Congress and subsequent efforts such as research funding by the National institutes of Health to force the inclusion of patient perceptions in health outcomes measures. However, perceptions are not as easily quantified as biological measures such as morbidity or mortality. Furthermore, the volume of patients and the need for comparisons of outcomes within and between groups necessitates the quantification of patient perceptions through standardized measures.

By embracing the conceptual definition of construct validity--defined as the instrument measuring the construct it is intended to measure--social workers, as patient advocates, can ensure that the patient's voice is not drowned out by the seduction of easy-to-administer rapid assessment instruments, or the elegance of sophisticated "scientific" measures. This is especially important whenever measures are administered to vulnerable populations with unique cultural values--such as immigrants from other parts of the world, people of color, gay and lesbian people, and those with a disability or chronic illness. Therefore, whenever measures are used with cultural minority groups, examination of the instruments' construct validity goes to the core of social work values of ethical practice, social justice, and respect for cultural diversity and difference (Witkin, 2001). As psychosocial experts in medical settings, social workers must be adept at articulating both the utility and the limitations of standardized measures on the basis of their construct validity for assessment of diverse populations.

Medical social work--which can be traced to the early 1900s--has been involved in various forms of assessment with cultural minority groups, immigrant groups, and vulnerable populations throughout its history (Berkman & Maramaldi, 2001a). Although standardized measures have great utility in practice (Berkman & Maramaldi, 2001b), social workers must be cautious not to blindly accept the psychometric properties of measures just because they sound sophisticated and have been developed by reputable statisticians and psychometricians. By contrast, whenever assessment instruments are used, social workers--while remaining problem solvers and core contributing members of interdisciplinary teams--should raise basic questions such as "Was this instrument developed (or 'normed') with the population we are administering it to?" or "How can we integrate our psychosocial understanding of individual patients with the findings from the standardized measures?" Social workers can do this without attacking the measures, their underlying theoretical assumptions, or the positivist epistemologies that drive them. By using the same language and theoretical base as the measurement theorists, an effective social worker can advocate for minority populations by articulating the underlying concepts of measurement theory much the same way she or he would articulate concepts of practice theory.

SOCIOPOLITICAL BACKGROUND

With passage of the Patients Outcome Research Act of 1989 (S. 702, 1989), the U.S. Congress proposed a patient-centered outcomes research program that went beyond the traditional assessment of biological measures of health to include broader issues of functional status, well-being, and patient satisfaction (Schipper, Clinch, & Olweny, 1996; Ware, 1995). At the same time, health care trends in the United States--such as advances in technology, drastic changes in delivery systems, new approaches to financing, and a shift in patient management beyond acute care to include long-term chronic illness--have increased the importance of consumer participation in the assessment of health care services (Berkman, 1996; Shortell, Gillies, & Devers, 1995; Volland, 1996). …

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