Background
The world population is aging [
1]. An aging population can be seen, not only in developed countries but also in developing countries [
2]. Also recent reports predicted that within 10 years, the elderly population over 65 years will increase from 7 to 14% by 2040 [
3]. The aging of population is often considered as a global public health success, although at the same time it is widely acknowledged as a public health challenge in high-income countries [
4,
5]. According to the 2011 census the population of elderly people accounted for 8.2% in Iran. Also predicted that this rate will increase to 22% in 2046 [
6,
7]. Thus, it is argued that if aging is a challenge for developed countries, therefore in the lower and middle-income countries such as Iran it is a more significant challenge [
4,
5].
Quality of life has become an end point in the evaluation of multi sector public policy, including health, social, community and environmental policies [
8]. Quality of life has long been used to evaluate various range of health and social care interventions [
9]. Quality of Life is a multidimensional concept and is defined as ‘individuals’ perceptions of their position in life in the context of the culture and value system in which they live, and in relationship to their goals, expectations and standard’ [
10]. We are witnessing a significant prolongation of life expectancy, but maintaining high quality of life is important. [
11]. In fact, Active aging is defined as ‘the process of optimizing the opportunities for physical, cognitive, and social health all over life with the aim of increasing a healthy life expectancy, efficiency and quality of life in older age’ which is more important than an increase in the aging population [
2,
12]. Thus, direct or indirect effects of age on quality of life led researchers in geriatrics interested in determining the factors that are related to the quality of life in older people [
2,
13,
14].
Since Health-Related Quality Of Life (HRQOL) of elderly people is becoming an important issue of public health, measuring quality of life of the elderly can be helpful for health program planning in future [
1]. So far, there are a large number of instruments for measuring quality of life. They are different widely in their conception, construct and content [
15]. Studies have shown that from 1970 instruments for measuring quality of life exponentially increased [
13]. There are several generic quality of life measures for elderly people including the Older People’s Quality of Life Questionnaire (CASP-19), the World Health Organization Quality of Life – OLD (WHOQOL-OLD) and the World Health Organization Quality of Life – AGE (WHOQOL-AGE) [
16‐
18]. One of the new instruments available to measure quality of life of elderly people is the Older People’s Quality of Life Questionnaire (OPQOL-35) [
19]. This instrument assesses quality of life in older people that can provide more information about quality of life in this population. In addition, this questionnaire has been shown recently not only excellent use in healthy people but can be used in old patients with mild or moderate dementia [
20]. This tool has been translated into various languages and has been used in several countries, including Britain [
21], Australia [
19], China [
22], Albania [
23], and India [
24]. The aim of this study was to evaluate the psychometric properties of the Persian version of OPQOL-35.
Discussion
The purpose of this study was to translate, conduct reliability and validity testing of the OPQOL in older people of Iran. Most of geriatric studies aimed to investigate the QOL in older people. However, an absolute prerequisite of these studies is the availability of a standard, valid and reliable questionnaire. The study findings revealed that the OPQOL is a multidimensional scale and has acceptable psychometric properties.
Using exploratory factor analysis the results demonstrated that the questionnaire contained eight factors that jointly explained 67.4% of the total variance observed. Factors 1 and 2 (life overall and health) contributed the most to the total variance 11.5 and 10.7, respectively. Accordingly, the greatest contribution of these two factors to the total variance is perfectly justifiable. Perhaps contribution of overall living conditions of older people and their concern about health are universal factors that might contribute to quality of life in this population. So, OPQOL is a multidimensional scale in older people. However, comparing factor structure of the OPQOL in different settings showed interesting results. Bowling (2010) evaluated the psychometric properties of the OPQOL in 3 groups of older people and reported the presence of 9 factors which explained cumulatively 60.5% of the total variance in QOL between respondents; where component 1 explained the largest proportion (24.0%) of the variance observed [
36]. Chen et al. (2014) evaluated the psychometric properties of the OPQOL in a sample of 618 older people living alone in China and reported 8 factors labelled ‘leisure and social activities’, ‘psychological well-being’, ‘health and independence’, ‘financial circumstances’, ‘social relationships’, ‘home and neighbourhood’, ‘culture/religion’ and ‘safety’, accounting for 63.7% of the variance. They reported that the factor structure was similar to the original version but differences were also found [
22]. The results of factor analysis suggest that the Persian version of the eight-factor structure of the OPQOL is consistent with that conducted by Bowling et al. (2010) and Chen et al. (2014). Consequently, the eight factors OPQOL has acceptable construct validity.
This study validated this scale by the use of CFA. CFA can evaluate goodness of fit results of factor structure of a scale, which can provide more precise and conclusive evaluation of latent factors [
44]. In the present study, data analysis confirmed that the final model was a good fit. The present study used AVE, MSV, and ASV for assessment of convergent and divergent validity. Convergent and divergent validity show satisfactory results for the following factors: health, social relationships and participation, home and neighborhood, financial circumstances, culture and religion. However the results did not support the convergent and divergent validity for three latent factors (Life overall, Independence, control over life, freedom and Psychological and emotional well-being). This result might be due to the low loading of one of the items in three factors. Moreover, high measurement errors may be another explanation for such observation. The measurement model did not show how measurement items logically and systematically contributed to the latent constructs [
45].
The study showed that the instrument’s reliability was excellent. More importantly, when the Cronbach’ alpha coefficients were calculated separately for the eight factors, high values for Cronbach’s alpha showed that good internal consistency exists for eight factors. The total Cronbach’s alpha of the Persian OPQOL was 0.92. The factor of ‘psychological and emotional well-being’ had a Coronbach’s alpha coefficient less than 0.70. Although the Cronbach’s alpha coefficient is enhanced by a large number of items, the high Cronbach’s alpha coefficient observed for the entire measure cannot be interpreted as indicating a unidimensional measure [
44]. Similarly studies reported good internal consistency for the OPQOL in different settings. Rathnayake et al. evaluated the quality of life and Its determinants among older people living in the rural community in Sri Lanka and reported 0.862 internal consistency coefficients [
46]. Also, Bilotta et al. reported 0.78 internal consistency coefficients for the Italian outpatient population [
21]. Furthermore, Bowling et al. (2011) found 0.9 Cronbach’s alpha coefficients in their research [
8]. Bazaadut evaluated the relationship between caregiver psychosocial factors and the quality of life of elderly at home in a sample of 400 older people living the Tamale township and reported 0.81 for internal consistency coefficients [
47]. In the study by Chen et al., who had calculated between 0.7–0.97 Cronbach’s alpha coefficients [
22].
The test-retest ICC of the OPQOL was between 0.88–0.95. The lowest ICC coefficient was related to the ‘psychological and emotional well-being’ subscale. According to Houser (2013), stability values of greater than 0.7 are considered as satisfactory. Test-retest is one of the common reliability assessment methods that assess the stability and the repeatability of an instrument. Polit et al. (2012) considered stability values of greater than 0.7, 0.8, and 0.9 as satisfactory, very good, and ideal, respectively [
48]. Accordingly, the Persian OPQOL showed very good stability. Bowling et al. (2011) reported between 0.4–0.78 test–retest [
8] and Chen et al. (2014) found 0.53–0.87 test-retest ICC in their research [
22]. Compared to the original version, the Persian version had better results with regard to the domains.
One of the integral needs of each community is to pay more attention to the elderly. As suggested identification of factors affecting on the quality of life may facilitate the design of interventions for the elderly [
23]. In fact as indicated by Bowling et al. OPQOL could have prognostic value in research on older people [
5]. Similarly our findings provide support to the prognostic value of QOL measures in older people. Thus, the OPQOL-35 might be superior to other broader measures of QOL in older age.
The present study has certain strengths and limitations. Inclusion of a teams of experts (translators, statistician, and methodologists) in designing the study and evaluating the questionnaire are the strengths. However, issues related to our sample might limit the findings. For instance we did not examined the sample for the emotional health. Thus this might have had impact on the study findings. In addition we did not collect data on clinical variable for testing criterion validity. This also might limit the findings. Finally as suggested convergent and divergent validity might be better tested by using another pre-validated quality of life questionnaire for the elderly (such as WHOQOL-OLDD etc).