Background
The concept of person-centred care is essential for mental health services [
1]. Subjective outcome measures are increasingly popular alongside measures of symptomatic remission or objective functioning [
2]. Western mental health policies and studies have focused on personal recovery as an important clinical outcome [
3,
4]. Personal recovery has been described as a unique process of changing one’s attitudes, values, feelings, goals, skills, and/or role and developing new meaning and purpose in life beyond the limits imposed by one’s illness [
5]. The concept of recovery extends beyond removal of all symptoms or the complete restoration of functionality. Recovery involves minimising the impact of mental illness and maximising well-being (e.g., by developing valued social roles) [
6]. A recent systematic review supported a conceptual framework of personal recovery consisting of the following factors: Connectedness; Hope and optimism about the future; Identity; Meaning in life; and Empowerment (abbreviated to CHIME) [
7].
Effective recovery assessment tools are needed for better recovery-oriented support. A recent review found that the Recovery Assessment Scale (RAS) has been the most widely used [
8,
9]; however, the Questionnaire About the Process of Recovery (QPR) is the only measure whose items all map onto the CHIME recovery framework [
10,
11].
Service users, researchers, and clinicians collaboratively designed the QPR; it has high internal consistency reliability and validity [
12]. An exploratory factor analysis (EFA) of the original 22-item version identified two factors; these were labelled ‘intrapersonal’ and ‘interpersonal’. Subscales examining these factors showed good internal consistency (intrapersonal: α = 0.94; interpersonal: α = 0.77) and good construct validity and reliability [
10]. A 15-item version has also been developed [
12] that is less burdensome and slightly more robust [
13]. Community-level recovery-promotion intervention research (REFOCUS) and pre-post-evaluation of Recovery College students have used the QPR as a primary outcome measure [
14,
15]. The 22-item Chinese version showed good validity and reliability as a measure of perceived levels of recovery [
16].
Mental health service reform in Japan has been slower than in the other OECD countries, with psychiatric hospital care being dominant [
17‐
19]. Japan requires community-based care and recovery-oriented services. Some person-centred service models were originally developed in Japan [
20,
21]; however, no research has examined personal recovery using a validated assessment tool for users participating in a specific mental health service in Japan.
Accordingly, this study aimed to develop a Japanese version of the QPR (QPR-J) and examine its validity and test–retest and internal consistency reliability. We also tested the possible factor structures of personal recovery among Japanese service users using EFA with the QPR-J.
Results
We developed the QPR-J (cf. Additional file
1) and tested the validity of the QPR-J in a community sample of Japanese individuals. We excluded 21 respondents who did not respond to the QPR-J and analysed data from 197 respondents (90.4% of the initial 218 service users; Table
1). Respondents were mostly females (61.9%), never married (72.6%), living with their families, and diagnosed with schizophrenia (49.2%). Respondents’ average age was 42.0 ± 10.9 years. A subsample completed the QPR-J questionnaire again two weeks later to examine test-retest reliability (
N = 10). They were mostly females (70.0%), were never married (50.0%), lived with their families, and had been diagnosed with schizophrenia (80.0%), and their average age was 44.7 ± 6.5 years.
Table 1Demographic characteristics of the study participants
Age, years | | 42.0
| 10.9
| 44.7
| 6.5
| 645.0
| 0.31 |
Missing | 9 | | 1 | | 1 | |
Gender |
| Male | 73 | 37.1 | 3 | 30.0 | 0.07 | 0.79 |
| Female | 122 | 61.9 | 7 | 70.0 | | |
| Missing | 2 | 1.0 | 0 | 0 | | |
Marital status |
| Unmarried | 143 | 72.6 | 5 | 50.0 | 4.61 | 0.10 |
| Currently married | 24 | 12.2 | 2 | 20.0 | | |
| Divorced/widowed | 26 | 13.2 | 3 | 30.0 | | |
| Missing data | 4 | 2.0 | 0 | 0 | | |
Living situationb
|
| Single | 47 | 23.9 | 3 | 30.0 | | |
| With parents | 97 | 49.2 | 5 | 50.0 | | |
| With sibling(s) | 29 | 14.7 | 2 | 20.0 | | |
| With partner | 16 | 8.1 | 2 | 20.0 | | |
| With child | 11 | 5.6 | 1 | 10.0 | | |
| Other | 27 | 13.7 | 0 | 0 | | |
| Missing | 3 | 1.5 | 0 | 0 | | |
Classification of mental disorderb
|
| Mental disorders due to psychoactive substance use | 21 | 10.7 | 0 | 0 | | |
| Schizophrenia | 97 | 49.2 | 8 | 80.0 | | |
| Mood disorders | 68 | 34.5 | 1 | 10.0 | | |
| Anxiety, Adjustment disorders | 19 | 9.6 | 0 | 10.0 | | |
| Intellectual disabilities | 4 | 2.0 | 1 | 10.0 | | |
| Developmental disorders | 16 | 8.1 | 1 | 10.0 | | |
| Epilepsy | 10 | 5.1 | 0 | 0 | | |
| Other | 21 | 10.7 | 1 | 10.0 | | |
| Not known | 9 | 4.6 | 0 | 0 | | |
| Missing | 5 | 2.5 | 0 | 0 | | |
Duration of the current service |
| Months | 43.7
| 59.0
| 30.86
| 26.3
| 613.50
| 0.91 |
| Missing | 10 | | 3 | | 3 | |
Table
2 presents mean scores for the examined variables. Table
3 presents QPR-J item-level ratings. The QPR-J items 9 and 13 were rated slightly higher than the other items.
Table 2Sample scores on the study measures (N = 197)
QPR-J | 197 | 4–86 | 56.8 | 12.8 |
Japanese RAS | 187 | 24–119 | 82.1 | 15.2 |
Japanese SF-8 (PCS) | 190 | 4–21 | 9.6 | 3.6 |
Japanese SF-8 (MCS) | 193 | 4–20 | 10.6 | 3.7 |
Table 3Item-level rating on the QPR-J (N = 197)
1 | I feel better about myself | 2.51 | 0.98 | 3 | 2–3 |
2 | I feel able to take chances in life | 2.41 | 1.16 | 2 | 2–3 |
3 | I am able to develop positive relationships with other people | 2.48 | 0.90 | 3 | 2–3 |
4 | I feel part of society rather than isolated | 2.24 | 1.07 | 2 | 2–3 |
5 | I am able to assert myself | 2.46 | 0.92 | 3 | 2–3 |
6 | I feel that my life has a purpose | 2.58 | 1.12 | 3 | 2–3 |
7 | My experiences have changed me for the better | 2.92 | 0.90 | 3 | 3–4 |
8 | I have been able to come to terms with things that have happened to me in the past and move on with my life | 2.68 | 0.98 | 3 | 2–3 |
9 | I am basically strongly motivated to get better | 3.37 | 0.79 | 4 | 3–4 |
10 | I can recognise the positive things I have done | 2.40 | 1.04 | 2 | 2–3 |
11 | I am able to understand myself better | 2.72 | 0.88 | 3 | 2–3 |
12 | I can take charge of my life | 2.28 | 1.03 | 2 | 2–3 |
13 | I am able to access independent support | 3.09 | 0.87 | 3 | 3–4 |
14 | I can weigh up the pros and cons of psychiatric treatment | 2.44 | 1.00 | 2 | 2–3 |
15 | I feel my experiences have made me more sensitive towards others | 2.61 | 0.92 | 3 | 2–3 |
16 | Meeting people who have had similar experiences makes me feel better | 2.87 | 0.99 | 3 | 2–4 |
17 | My recovery has helped challenge other peoples views about getting better | 2.24 | 0.95 | 2 | 2–3 |
18 | I am able to make sense of my distressing experiences | 2.34 | 1.11 | 2 | 2–3 |
19 | I can actively engage with life | 2.45 | 1.08 | 3 | 2–3 |
20 | I realise that the views of some mental health professionals is not the only way of looking at things | 2.72 | 0.96 | 3 | 2–3 |
21 | I can take control of aspects of my life | 2.28 | 0.93 | 2 | 2–3 |
22 | I can find the time to do the things I enjoy | 2.77 | 0.96 | 3 | 2–3 |
Validity testing
The scores on the total QPR-J, intrapersonal and interpersonal subscales were significantly and positively correlated with the scores on the RAS and SF-8 MCS (Table
4). These results indicated adequate convergent validity for each scale.
Table 4Pearson’s correlation coefficients on the QPR-J intrapersonal (17 items), QPR interpersonal (5 items)
Japanese RAS | 0.77** | 0.78** | 0.54** |
Japanese SF-8 (PCS) | 0.10 | 0.11 | 0.05 |
Japanese SF-8 (MCS) | 0.25** | 0.28** | 0.16** |
Reliability testing
The ICC values for the full version (0.85 [95% CI 0.35–0.97]), intrapersonal subscale (0.85 [95% CI 0.35–0.97]), and interpersonal subscale (0.89 [95% CI 0.55–0.97]) were satisfactory.
Cronbach’s alpha coefficients indicated excellent internal consistency for the full version, intrapersonal subscale (α = 0.91 and 0.90 respectively). The internal consistency of the interpersonal subscale was acceptable but relatively low (α = 0.65).
Confirmatory factor analysis
Goodness of fit index for the original 2-factor model were reasonable fit (CFI = 0.87 and RMSEA = 0.07) (Tables
5 and
6).
Table 5Results of the confirmatory factor analysis: Goodness-of-fit indices for the two-factor QPR-J models
0.87 | 0.07 | 553.22 | 419.22 | 208.00 | < 0.001 |
Table 6Item loadings for the confirmatory factor analysis
No | Item | Intrapersonal | Interpersonal |
1 | I feel better about myself | 0.56 | |
2 | I feel able to take chances in life | 0.54 | |
3 | I am able to develop positive relationships with other people | 0.61 | |
4 | I feel part of society rather than isolated | 0.61 | |
5 | I am able to assert myself | 0.51 | |
6 | I feel that my life has a purpose | 0.68 | |
7 | My experiences have changed me for the better | 0.70 | |
8 | I have been able to come to terms with things that have happened to me in the past and move on with my life | 0.75 | |
9 | I am basically strongly motivated to get better | 0.27 | |
10 | I can recognise the positive things I have done | 0.68 | |
11 | I am able to understand myself better | 0.57 | |
12 | I can take charge of my life | 0.59 | |
13 | I am able to access independent support | 0.42 | |
18 | I am able to make sense of my distressing experiences | 0.64 | |
19 | I can actively engage with life | 0.78 | |
21 | I can take control of aspects of my life | 0.60 | |
22 | I can find the time to do the things I enjoy | 0.58 | |
14 | I can weigh up the pros and cons of psychiatric treatment | | 0.56 |
15 | I feel my experiences have made me more sensitive towards others | | 0.65 |
16 | Meeting people who have had similar experiences makes me feel better | | 0.52 |
17 | My recovery has helped challenge other peoples views about getting better | | 0.73 |
20 | I realise that the views of some mental health professionals is not the only way of looking at things | | 0.22 |
Exploratory factor analysis
An EFA was conducted using maximum likelihood estimation with Promax rotation. Bartlett’s Test of Sphericity (χ2 = 1, 756,
p < 0.001) and the KMO test (0.90) indicated that the correlation matrix was factorable. Five factors had eigenvalues >1.0. Item factor loading was 0.34–0.70 which was not considered as good loadings. In addition, one factor (Factor 5) had only 2 item (Table
7). The five factors accounted for 47.64% of the total scale variance. Factor 1 (Positive relationships and redefining the meaning of life, 8 items) accounted for 17.79%, Factor 2 (Improving the skills of self-assessment and literacy of the treatment, 2 items) accounted for 20.61%, Factor 3 (Accepting the illness and positive decision making, 6 items) accounted for 3.53%, Factor 4 (Support from others and motivation to change, 4 items) accounted for 3.41% and Factor 5 (Self-management, 2 items) accounted for 2.30%.
Table 7Item loadings for the exploratory factor analysis and statistical metrics (Cronbach’s alpha for internal consistency and ICC values for test-retest reliability)
Intra | 4 | I feel part of society rather than isolated | 0.76
| −0.11 | −0.05 | −0.04 | 0.13 |
Intra | 5 | I am able to assert myself | 0.69
| 0.00 | 0.01 | −0.17 | −0.04 |
Intra | 3 | I am able to develop positive relationships with other people | 0.57
| −0.28 | 0.15 | 0.27 | −0.01 |
Intra | 6 | I feel that my life has a purpose | 0.54
| 0.18 | 0.21 | −0.09 | −0.15 |
Intra | 10 | I can recognise the positive things I have done | 0.44
| 0.41 | 0.02 | −0.13 | −0.03 |
Inter | 17 | My recovery has helped challenge other peoples views about getting better | 0.44
| 0.16 | −0.15 | 0.37 | 0.00 |
Intra | 18 | I am able to make sense of my distressing experiences | 0.44
| 0.43 | −0.11 | −0.04 | −0.02 |
Intra | 19 | I can actively engage with life | 0.36
| 0.10 | 0.26 | 0.15 | 0.09 |
Intra | 11 | I am able to understand myself better | −0.14 | 0.78
| 0.09 | 0.03 | −0.01 |
Inter | 14 | I can weigh up the pros and cons of psychiatric treatment | −0.03 | 0.69
| −0.05 | 0.01 | 0.08 |
Intra | 22 | I can find the time to do the things I enjoy | 0.17 | −0.11 | 0.57
| −0.19 | 0.21 |
Intra | 1 | I feel better about myself | 0.13 | −0.08 | 0.56
| 0.09 | −0.02 |
Intra | 2 | I feel able to take chances in life | 0.11 | 0.29 | 0.50
| −0.17 | −0.12 |
Intra | 8 | I have been able to come to terms with things that have happened to me in the past and move on with my life | 0.16 | 0.12 | 0.42
| 0.22 | 0.02 |
Intra | 7 | My experiences have changed me for the better | 0.18 | 0.07 | 0.39
| 0.27 | −0.02 |
Inter | 20 | I realise that the views of some mental health professionals is not the only way of looking at things | −0.21 | 0.02 | 0.32
| 0.11 | 0.13 |
Intra | 9 | I am basically strongly motivated to get better | −0.29 | −0.05 | 0.13 | 0.73
| −0.14 |
Inter | 16 | Meeting people who have had similar experiences makes me feel better | 0.16 | 0.07 | −0.18 | 0.54
| −0.06 |
Intra | 13 | I am able to access independent support | 0.15 | −0.04 | 0.07 | 0.37
| 0.00 |
Inter | 15 | I feel my experiences have made me more sensitive towards others | −0.20 | 0.36 | 0.06 | 0.36
| 0.20 |
Intra | 21 | I can take control of aspects of my life | 0.04 | 0.05 | 0.14 | −0.17 | 0.94
|
Intra | 12 | I can take charge of my life | 0.37 | 0.09 | −0.12 | 0.17 | 0.26
|
| Cronbach’s alpha | 0.89 | 0.72 | 0.82 | 0.87 | 0.80 | |
| ICC values | 0.89 | 0.72 | 0.82 | 0.87 | 0.80 | |
| (95% CI) | (0.54–0.97) | (−0.11–0.93) | (0.21–0.96) | (0.48–0.97) | (0.18–0.95) | |
| Extraction Sums of Squared Loadings |
| Total | 3.91 | 4.53 | 0.78 | 0.75 | 0.51 | |
| % of variance explained | 17.79 | 20.61 | 3.53 | 3.41 | 2.30 | |
| Cumulative % of variance explained | 17.79 | 38.40 | 41.93 | 45.34 | 47.64 | |
| Rotation |
| Total | 6.63 | 5.42 | 5.38 | 4.20 | 3.45 | |
Discussion
This study aimed to develop and examine the validity and reliability of the QPR-J. The results indicated adequate convergent validity. The QPR-J’s full version, and intrapersonal subscale showed good test-retest reliability and excellent internal consistency reliability.
The scores on the total QPR-J, intrapersonal, and interpersonal subscales were significantly and positively correlated with the scores on the RAS-J (
r = 0.77, 0.78, and 0.54, respectively), which is slightly above the correlations reported in a previous study reported between the QPR and RAS (
r = 0.73, 0.75, and 0.46, respectively) [
13]. The scores on the total QPR-J were also significantly and positively correlated with the scores on the SF-8 MCS, which is in line with previous studies reporting correlations between the original QPR and the Personal and Social Performance Scale (including socially useful activities and personal and social relationships) [
12], the QPR-Chinese and Schizophrenia Quality of Life scale [
16], and the QPR-Swedish and General Quality of Life [
34]. These results indicate that the QPR-J has satisfactory convergent validity.
The results also indicated that the QPR-J has satisfactory test–retest reliability (ICC values for the full version: 0.85 [95% CI 0.35–0.97], intrapersonal subscale: 0.85 [95% CI 0.35–0.97], and interpersonal subscale: 0.89 [95% CI 0.55–0.97]). Test–retest reliability of the original QPR (n = 88) was ‘fair to good’ for the total QPR (ICC = 0.74, 95% CI 0.63–0.82) and ‘good’ for intrapersonal (ICC = 0.75, 95% CI 0.64–0.83) and interpersonal (ICC = 0.66, 95% CI 0.53–0.77). The test–retest assessments in our study were performed with a small sample size (N = 10). Therefore, future validation studies of the Japanese version of the questionnaire should better assess the test–retest reliability of the measure. Future validation studies of the QPR-J with large sample sizes sufficient to evaluate test–retest reliability are needed.
Cronbach’s alpha coefficients indicated excellent internal consistency for the full version and intrapersonal subscale (α = 0.91 and 0.90, respectively). The internal consistency of the interpersonal subscale was acceptable but relatively low (α = 0.65). These results were consistent with internal consistency of the original QPR (α = 0.89, 0.90, and 0.49). Previous studies indicated excellent internal consistency for the full version (QPR-Chinese: α = 0.90 and QPR-Swedish: α = 0.91). An independent evaluation of the psychometric properties of the original QPR [
13] recommended 15-item versions excluding the QPR interpersonal subscale for use in research and clinical practice because of the poor internal consistency of the QPR interpersonal subscale. Further research to evaluate the psychometric properties of QPR-J with a sufficient sample size is needed.
An EFA of the original 22-item version identified two factors; these were labelled ‘intrapersonal’ and ‘interpersonal’ [
10]. The EFA supported a 3-factor structure (Self-Empowerment, Effective Interpersonal Relationships, and Rebuilding Life) [
16] in the QPR-Chinese and one-factor structure summarized as intrapersonal factors in the QPR-Swedish [
34]. An EFA of the QPR-J identified five factors. When compared with the two factors of the original scale [
10], the ‘Interpersonal’ subscale of the original QPR was divided into two factors; ‘Factor 1: Positive relationships and redefining the meaning of life’ (Item 17) and ‘Factor 4: Support from others and motivation to change’ (Item 15 and 16). Further, the attitude of Japanese people toward others and toward their life may be divided into ‘active relationships’ (Positive relationships and redefining the meaning of life) and ‘passive relationships’ (Support from others and motivation to change). Cultural differences in values of social relationships might affect these classifications. Japanese are strongly motivated toward relational harmony and interdependence [
35]. An EFA of the QPR-J extracted ‘recovery process through positive relationship with others (Factor 1)’ and ‘recovery process within support from others (Factor 4)’. Japanese may build positive relationships (items 4, 5, 3, and 17) and recognise and define the meaning of life through the relationship (items 6, 10, 18, and 19) [Factor 1]. In addition, belongingness and support from others (item 16 and 13) and support for others (item 15) might motivate them to change (item 9) [Factor 4]. Some of the factor loadings were less than .50, which indicated poor factor loading, and the five factors accounted for 47.64% of the total scale variance. These trends of poor loadings did not change even after limiting the diagnosis to schizophrenia and/or mood disorders (Additional file
2: Table S1 and Table S2). Further research with a large sample size sufficient to allow EFA sufficiently is needed.
The result of the CFA indicated reasonable goodness of fit indexes for the original 2-factor model. Therefore, we adopted the factor structure extracted from the original 2-factor based on our CFA results. Some of the items had a factor loading below 0.5 in the CFA. Item 20 (‘I realise that the views of some mental health professionals is not the only way of looking at things’) had a factor loading 0.22 in the QPR-J and 0.38 in the QPR [
13]. It may be too vague and difficult for the participants to think about “some mental health professionals” and “way of looking at things”. Item 13 (‘I am able to access independent support’) also had low factor loadings in the QPR-J (0.27). All the participants were recruited from community mental health services, and most used independent support. A careful review of item wording and diversity of sampling is needed in a replication study.
The first research examining recovery was qualitative and originated in the Western Europe and North America. Some studies that examined recovery have discussed international differences in the conceptualisation of personal recovery [
36,
37]. A cross-cultural study examining recovery using the RAS found that “personal confidence and hope” and “reliance on others” varied in conceptualisation between the USA and Japanese samples [
38]. Another cross-cultural study examining well-being found that personal control and relational harmony most strongly predicted well-being in the USA and Japan, respectively [
39]. A cultural comparison study suggested that patients from Western European and Japanese cultures have different typical recovery needs [
40]. Future research should further examine the Japanese conceptualisation of recovery and well-being.
Here are some of the comments we received from the participants: “I think that answering the QPR-J was a good opportunity to think about myself”, ‘I hope the staff will receive recovery oriented-education and provide better services’. Based on such comments, we believe that researchers should assess the process of recovery using the QPR-J and implement the best practices of recovery-oriented services in Japan.
This study has the following limitations. First, we drew respondents from suburbs in specific urban areas and using mental health services; therefore, the sample may not accurately represent the Japanese population. Further research is needed with more diverse samples. Second, Japan and the UK may have importantly different cultural and mental health care contexts. Future research should develop or adapt questionnaires to suit the Japanese cultural context. Finally, as we mentioned above, future validation studies with large sample sizes sufficient to evaluate test–retest reliability and to allow sufficient EFA of the QPR-J are needed.