Academic journal article Journal of Nursing Measurement

Validation of Diabetes Health-Related Quality-of-Life Instruments Using Cognitive Interviewing with Older African Americans

Academic journal article Journal of Nursing Measurement

Validation of Diabetes Health-Related Quality-of-Life Instruments Using Cognitive Interviewing with Older African Americans

Article excerpt

The reliability and validity of two diabetes-specific quality-of-life instruments were examined with aging African Americans with limited literacy. Cognitive interviews with 15 persons and content analysis were conducted. Participants' mean age was 72 years, and 40% had less than a high school education. Most observed problems with the surveys related to comprehension and response categories. Respondents had difficulty distinguishing between certain functional limitations and/or level of satisfaction as being associated with chronic illness or aging. This study underscores the need for research with special populations on the appropriateness of instruments previously validated and shown reliable for more general populations. While cognitive interviewing is resource intensive, ignoring this investment may result in inappropriate interpretations about the effectiveness of interventions to improve care and outcomes, understand differences, and eliminate disparities.

Keywords: cognitive interviewing; health-related quality of life; African Americans; aged; elders

Older African Americans have a very high burden of type 2 diabetes, and a wide variety of medical and public health interventions have been designed and implemented to address this challenging chronic condition. Significant advances in prevention and health care have led to an increased average life expectancy, accompanied by a substantial proportion of aging adults living with chronic health conditions such as heart disease, diabetes, and cancer. The overarching goals of Healthy People 2010 are concurrently to increase life expectancy and to improve quality of life (QoL) as well as to eliminate disparities that exist among segments of our population (U.S. Department of Health and Human Services [USDHHS], 2000). Health-related quality of life (HRQoL) has gained significant attention as an important outcome measure. Outcomes research provides an evidence base that ideally drives informed decision making for program planners, patients, and clinicians (Agency for Healthcare Research and Quality [AHRQ], 2000).

Measurement of outcomes has historically focused on traditional biomedical markers and clinical end points. In diabetes care, such measures include A1C, lipids, and blood pressure levels. These clinical measures are clearly critical to assessing the impact of interventions. However, they fail to assess or acknowledge adequately the patient's perspective or context, which may differ from the clinical parameters or proxy assessments made by health professionals (Woodend, Nair, & Tang, 1997). As public health proponents work to understand and eliminate apparent disparities in health and health care (Institute of Medicine [IOM], 2003), valid measurement of various process, impact, and outcome indicators are critical. HRQoL is one such indicator, and its use as a valid measure to be included in intervention studies is well established (Brown et al., 2004; Steed, Cooke, & Newman, 2003).

Few instruments purporting to measure HRQoL have been specifically pretested and validated in African American populations. Given the need for valid and reliable instruments for use within specific populations for research and to evaluate intervention, we undertook a qualitative study to better understand the appropriateness of existing HRQoL instruments with elder African Americans with diabetes. Study results from cognitive interviews and content analyses of two diabetes-specific HRQoL instruments are presented. Using an analysis coding system proposed by Willis, Schechter, and Whitaker, (1999), the following potential sources of cognitive process problems were examined: (a) comprehension/communication, (b) recall/computational, (c) bias/ sensitivity, and (d) response category. Further, the effects of within-language cultural variations that may influence reliability and content or construct validity were considered.

BACKGROUND AND CONCEPTUAL FRAMEWORK

Definition, Dimensions, and Issues

HRQoL is an individual's perception of his or her illness; it is that personal sense of physical and mental health and the ability to react to factors in the physical and social environments (USDHHS, 2000). …

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