Skip to main content
Erschienen in: BMC Psychiatry 1/2017

Open Access 01.12.2017 | Research article

The Japanese version of the questionnaire about the process of recovery: development and validity and reliability testing

verfasst von: Akiko Kanehara, Risa Kotake, Yuki Miyamoto, Yousuke Kumakura, Kentaro Morita, Tomoko Ishiura, Kimiko Shimizu, Yumiko Fujieda, Shuntaro Ando, Shinsuke Kondo, Kiyoto Kasai

Erschienen in: BMC Psychiatry | Ausgabe 1/2017

Abstract

Background

Personal recovery is increasingly recognised as an important outcome measure in mental health services. This study aimed to develop a Japanese version of the Questionnaire about the Process of Recovery (QPR-J) and test its validity and reliability.

Methods

The study comprised two stages that employed the cross-sectional and prospective cohort designs, respectively. We translated the questionnaire using a standard translation/back-translation method. Convergent validity was examined by calculating Pearson’s correlation coefficients with scores on the Recovery Assessment Scale (RAS) and the Short-Form-8 Health Survey (SF-8). An exploratory factor analysis (EFA) was conducted to examine factorial validity. We used intraclass correlation and Cronbach’s alpha to examine the test-retest and internal consistency reliability of the QPR-J’s 22-item full scale, 17-item intrapersonal and 5-item interpersonal subscales. We conducted an EFA along with a confirmatory factor analysis (CFA).

Results

Data were obtained from 197 users of mental health services (mean age: 42.0 years; 61.9% female; 49.2% diagnosed with schizophrenia). The QPR-J showed adequate convergent validity, exhibiting significant, positive correlations with the RAS and SF-8 scores. The QPR-J’s full version, subscales, showed excellent test-retest and internal consistency reliability, with the exception of acceptable but relatively low internal consistency reliability for the interpersonal subscale. Based on the results of the CFA and EFA, we adopted the factor structure extracted from the original 2-factor model based on the present CFA.

Conclusion

The QPR-J is an adequately valid and reliable measure of the process of recovery among Japanese users with mental health services.
Hinweise

Electronic supplementary material

The online version of this article (https://​doi.​org/​10.​1186/​s12888-017-1520-y) contains supplementary material, which is available to authorized users.
A correction to this article is available online at https://​doi.​org/​10.​1186/​s12888-020-2430-y.
Abkürzungen
ICC
Intraclass correlation coefficients
KMO
Kaiser-Meyer-Olkin
QOL
Quality of life
QPR
Questionnaire about the process of recovery
RAS
Recovery assessment scale
SF-8 (MCS)
Short form-8 (Mental component summary)
SF-8 (PCS)
Short form-8 (Physical component summary)

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 [1719]. 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.

Methods

Study designs

The study was performed in two stages, using a cross-sectional and prospective cohort study design. Specifically, the first stage used a cross sectional design to develop and validate the QPR-J in users of mental health services, while the second stage used a prospective cohort design to evaluate the test-retest reliability of the tool in a subset of the participants.

Participants

We conducted a survey of mental health-related service users using the Japanese version of the QPR (QPR-J). The sample was recruited from 14 community mental health services in the suburbs of Tokyo. All the participants recruited from community mental health services had been diagnosed with mental illness and/or mental disorders by a psychiatrist. In our survey, the participants selected their own diagnosis, including the categories ‘other’ and ‘not known’, by themselves (self-report). Inclusion criteria were as follows: (1) aged ≥18 years, (2) able to participate and give informed consent, and (3) having any mental disorder. We explained the study to the participants. All participants provided a written indication of informed consent. Participation was voluntary. This study was approved by the Ethical Committee of the Faculty of Medicine, The University of Tokyo [approval No. 10890].

Development of the Japanese version of the QPR

The original QPR contains 22 items. Responses were made on a 5-point Likert scale (0 = strongly disagree, 4 = strongly agree). Scores’ possible range is 0–88. The intrapersonal and interpersonal subscales contain 17 and 5 items, respectively (possible score ranges: 0–68 and 0–20). Higher scores indicate greater recovery.
The following procedure was used to translate the QPR [22]. First, we obtained permission to translate the QPR from its original authors. Three native Japanese speakers independently translated the original instrument into Japanese. Eleven mental health professionals reviewed the three translations and collaborated to create a draft translation of the QPR-J. Second, the draft version was back-translated into English by a professional translator who was a native English speaker following the guidelines for the translation and adaptation process for patient-reported outcomes measures [22]. Then, another native professional translator checked the back-translation of the QPR. We refined the draft after we compared the original questionnaire with the back-translation. Third, the authors of the original QPR and the authors of the present study revised the back-translation based on the original concept. Fourth, we conducted pre-tests for users and peer staffs to confirm whether the items on the pre-final questionnaire were subjectively relevant and appropriate to the participants. We asked them what they thought about the items after answering the questionnaire. The participants reported that the items were easy to understand and relevant to their life situation. The survey used the finalised QPR-J; surveying ran from October to December 2015 (Additional file 1).

Validity testing

The Recovery Assessment Scale (RAS) is closely correlated with the original QPR [13]. Quality of life (QOL) is closely correlated with recovery [23]. Accordingly, the RAS and a scale measuring QOL were used to examine the QPR-J’s convergent validity.
The RAS is a user-rating measure examining personal recovery developed in the USA; a 41-item version and a 24-item version exist [9, 23]. Responses use a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Higher scores indicate greater recovery. The validity and reliability of both versions of the RAS have been supported in the USA (Corrigan 1999, Corrigan 2004). The validity and reliability of the Japanese version of the 24-item RAS have been supported [24].
The Short Form-8 (SF-8) is a self-report measure that assesses health-related QOL; it contains subscales examining general physical health (the Physical Component Summary: PCS) and mental health (the Mental Component Summary: MCS). Higher scores indicate better QOL [25]. The validity and reliability of the SF-8–Japanese Version have been supported [26].
The QPR-J’s convergent validity was examined by calculating the Pearson product-moment correlation between the Japanese RAS and the Japanese SF-8’s mental health subscale (MCS). Values of 0.40—0.70 and >0.70 were considered moderate and strong, respectively.

Reliability testing

The test-retest reliability was assessed in a subsample of participants who completed the survey again after a two-week interval (N = 10). Intraclass correlation coefficients (ICC) were calculated as ICC (2, 1) using a two-way random effects model. We considered ICCs >0.80 to indicate excellent agreement [27].
Internal consistency reliability was examined using Cronbach’s alpha [28] calculated between scores on the full version, intrapersonal and interpersonal subscales. We considered alpha coefficients ≥0.70 satisfactory [29] and those ≥0.60 acceptable [30, 31].

Confirmatory factor analysis

We performed a confirmatory factor analysis (CFA) to test the fitness of the data to the factor structure extracted from the original 2-factor subscales of the English scale. The two factors were “the intrapersonal subscale” (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 18, 19, 21, 22) and “the interpersonal subscale” (14, 15, 16, 17, 20). We reported the goodness of fit index including the comparative fit index (CFI) and the root mean square error of approximation (RMSEA). The acceptability of model fit was judged by the recommended standards: CFI > 0.90 and the RMSEA values of 0.06 or less for a good fit and 0.08 or less for a reasonable fit [32].

Exploratory factor analysis

We conducted an EFA along with the CFA to compare the original factor solution to the one that would emerge from the data. We performed an EFA to explore factor structure of the QPR-J and reported all statistical metrics (Cronbach’s alpha for internal consistency and the test-retest reliability) related to the yielded factors.
The QPR-J’s factorial validity was evaluated using maximum likelihood estimation with Promax rotation. Maximum likelihood estimation gives us the best results when the data are relatively normally distributed. ‘Maximum likelihood estimation allows for the computation of a wide range of indexes of the goodness of fit of the model [and] permits statistical significance testing of factor loadings and correlations among factors and the computation of confidence intervals’ [33].
Eigenvalues ≥1.00 were considered to indicate factors. Assumptions regarding matrix identity and sampling adequacy were evaluated using Bartlett’s Test of Sphericity and the Kaiser-Meyer-Olkin (KMO) test. Inter-factor correlations for the final model were examined to determine the extent of correlations among factors.
All analyses were conducted using IBM SPSS Statistics, version 22.0 (IBM SPSS, Armonk, NY, USA). The CFA was conducted using IBM SPSS AMOS, version 22.0 (IBM SPSS, Armonk, NY, USA).

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 1
Demographic characteristics of the study participants
Characteristics
 
Test (N = 197)
Retest (N = 10)
Chi-squared test (Mann-Whitney U test) c
 
N (mean)
% (SD a)
N (mean)
% (SD a)
chi-sq (U)
p-value
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
 
a: Standard deviation
b: Total percentage will exceed 100 due to multiple responses
c: Chi-squared and Mann-Whitney U tests were used to compare the proportions of the demographic characteristics between participants and non-participants in the retest
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 2
Sample scores on the study measures (N = 197)
Scalea
N
Range
Mean
Standard Deviation
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
a: RAS: the Recovery Assessment Scale
SF-8 (PCS): Short Form-8 (Physical Component Summary)
SF-8 (MCS): Short Form-8 (Mental Component Summary)
Table 3
Item-level rating on the QPR-J (N = 197)
No.
Item
Mean
Standard Deviation
Median
IQRa
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
a: IQR: Interquartile range

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 4
Pearson’s correlation coefficients on the QPR-J intrapersonal (17 items), QPR interpersonal (5 items)
Scalea
Full-version
Intrapersonal subscale
Interpersonal subscale
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**
a: RAS: the Recovery Assessment Scale
SF-8 (PCS): Short Form-8 (Physical Component Summary)
SF-8 (MCS): Short Form-8 (Mental Component Summary)
**p < 0.01

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 5
Results of the confirmatory factor analysis: Goodness-of-fit indices for the two-factor QPR-J models
CFI
RMSEA
AIC
χ2
df
p
0.87
0.07
553.22
419.22
208.00
< 0.001
CFI: Confirmatory fit index
RMSEA: Root mean square error of approximation
AIC: Akaike information criterion
Table 6
Item loadings for the confirmatory factor analysis
  
Two-factor model
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 7
Item loadings for the exploratory factor analysis and statistical metrics (Cronbach’s alpha for internal consistency and ICC values for test-retest reliability)
   
loading
Intra/Inter
No
Item
Factor 1
Factor 2
Factor 3
Factor 4
Factor 5
   
Positive relationships and redefining the meaning of life
Improving the skills of self-assessment and literacy of the treatment
Accepting the illness and positive decision making
Support from others and motivation to change
Self-management
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
 
Boldface type indicates the highest factor loading

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.

Conclusions

The QPR-J is valid, and it reliably measures recovery among mental health service users in Japan.

Acknowledgements

The authors express their gratitude to Dr. Anthony P. Morrison and colleagues for permitting the development of the QPR-J. We also thank Drs. Mike Slade, Geoff Shepherd, and Jane McGregor for their kind introduction to the concept of personal recovery and recovery-oriented service.

Funding

This study was partially supported by JSPS KAKENHI Grant Number JP16H06395, JP16H06398, JP16H06399, and JP16K21720. This research was also partially supported by Research and Development Grants for Comprehensive Research for Persons with Disabilities from Japan Agency for Medical Research and development, AMED (Grant Number: 16dk0307066 and 16dk0307059). The funders had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Availability of data and materials

The dataset supporting the conclusions of this article is not available due to ethical restrictions.

Authors’ information

Not applicable.
All participants received an explanation of the study’s aims and provided a written indication of informed consent. Participation was voluntary. This study was approved by the Ethical Committee at the Faculty of Medicine, The University of Tokyo [Approval No. 10890].
Not applicable.

Competing interests

The authors declare no conflict of interest.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://​creativecommons.​org/​publicdomain/​zero/​1.​0/​) applies to the data made available in this article, unless otherwise stated.
Literatur
1.
Zurück zum Zitat Thornicroft G, Deb T, Henderson C. Community mental health care worldwide: current status and further developments. World Psychiatry. 2016;15(3):276–86.PubMedPubMedCentralCrossRef Thornicroft G, Deb T, Henderson C. Community mental health care worldwide: current status and further developments. World Psychiatry. 2016;15(3):276–86.PubMedPubMedCentralCrossRef
2.
Zurück zum Zitat Steptoe A, Deaton A, Stone AA. Subjective wellbeing, health, and ageing. Lancet. 2015;14(385(9968)):640–8.CrossRef Steptoe A, Deaton A, Stone AA. Subjective wellbeing, health, and ageing. Lancet. 2015;14(385(9968)):640–8.CrossRef
4.
Zurück zum Zitat Mehta N, Croudace T, Davies S. Public mental health: evidenced based priorities. Lancet. 2014;385:1472–5.PubMedCrossRef Mehta N, Croudace T, Davies S. Public mental health: evidenced based priorities. Lancet. 2014;385:1472–5.PubMedCrossRef
5.
Zurück zum Zitat Anthony WA. Recovery from mental illness: the guiding vision of the mental health system in the 1990s. Psychatr Rehabil J. 1993;16:11–23. Anthony WA. Recovery from mental illness: the guiding vision of the mental health system in the 1990s. Psychatr Rehabil J. 1993;16:11–23.
7.
Zurück zum Zitat Leamy M, Bird V, Le Boutillier C, Williams J, Slade M. Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. Br J Psychiatry. 2011;199(6):445–52.PubMedCrossRef Leamy M, Bird V, Le Boutillier C, Williams J, Slade M. Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. Br J Psychiatry. 2011;199(6):445–52.PubMedCrossRef
8.
Zurück zum Zitat Giffort D, Schmook A, Woody C, Vollendorf C, Gervain M. 2005. Recovery assessment scale (RAS). In: Campbell-Orde, T., Chamberlin, J., Carpenter, J., Leff, H.S. (Eds.), Measuring the Promise: A Compendium of Recovery Measures, vol. 2. Human Services Research Institute, Cambridge, MA, pp. 60–64, 194–197. https://www.power2u.org/downloads/pn-55.pdf Accessed 25 Oct 2017. Giffort D, Schmook A, Woody C, Vollendorf C, Gervain M. 2005. Recovery assessment scale (RAS). In: Campbell-Orde, T., Chamberlin, J., Carpenter, J., Leff, H.S. (Eds.), Measuring the Promise: A Compendium of Recovery Measures, vol. 2. Human Services Research Institute, Cambridge, MA, pp. 60–64, 194–197. https://​www.​power2u.​org/​downloads/​pn-55.​pdf Accessed 25 Oct 2017.
9.
Zurück zum Zitat Corrigan PW, Salzer M, Ralph RO, Sangster Y, Keck L. Examining the factor structure of the recovery assessment scale. Schizophr Bull. 2004;30(4):1035–41.PubMedCrossRef Corrigan PW, Salzer M, Ralph RO, Sangster Y, Keck L. Examining the factor structure of the recovery assessment scale. Schizophr Bull. 2004;30(4):1035–41.PubMedCrossRef
10.
Zurück zum Zitat Neil S, Pitt L, Kilbride M, Welford M, Nothard S, Sellwood W, Morrison T. The questionnaire about the process of recovery (QPR): a measurement tool developed in collaboration with service users. Psychosis. 2009;1(2):145–55.CrossRef Neil S, Pitt L, Kilbride M, Welford M, Nothard S, Sellwood W, Morrison T. The questionnaire about the process of recovery (QPR): a measurement tool developed in collaboration with service users. Psychosis. 2009;1(2):145–55.CrossRef
11.
Zurück zum Zitat Shanks V, Williams J, Leamy M, Bird VJ, Le Boutillier C, Slade M. Measures of personal recovery: a systematic review. Psychiatr Serv. 2013;64(10):974–80.PubMedCrossRef Shanks V, Williams J, Leamy M, Bird VJ, Le Boutillier C, Slade M. Measures of personal recovery: a systematic review. Psychiatr Serv. 2013;64(10):974–80.PubMedCrossRef
12.
Zurück zum Zitat Law H, Neil S, Dunn G, Morrison A. Psychometric properties of the questionnaire about the process of recovery (QPR). Schizophr Res. 2014;156:184–9.PubMedCrossRef Law H, Neil S, Dunn G, Morrison A. Psychometric properties of the questionnaire about the process of recovery (QPR). Schizophr Res. 2014;156:184–9.PubMedCrossRef
13.
Zurück zum Zitat Williams J, Leamy M, Pesola F, Bird V, Le Boutillier C, Slade M. Psychometric evaluation of the questionnaire about the process of recovery (QPR). Br J Psychiatry. 2015;207(6):551–5.PubMedCrossRef Williams J, Leamy M, Pesola F, Bird V, Le Boutillier C, Slade M. Psychometric evaluation of the questionnaire about the process of recovery (QPR). Br J Psychiatry. 2015;207(6):551–5.PubMedCrossRef
14.
Zurück zum Zitat Slade M, Bird V, Clarke E, Le Boutillier C, McCrone P, Macpherson R, et al. Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomised, controlled trial. Lancet Psychiatr. 2015;27; 2(6):503–514.PubMedCrossRef Slade M, Bird V, Clarke E, Le Boutillier C, McCrone P, Macpherson R, et al. Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomised, controlled trial. Lancet Psychiatr. 2015;27; 2(6):503–514.PubMedCrossRef
15.
Zurück zum Zitat Meddings S, Campbell E, Guglietti S, Lambe H, Locks L, Byrne D, et al. From service user to student—the benefits of recovery college. Clin Psychol Forum. 2015;268:32–7. Meddings S, Campbell E, Guglietti S, Lambe H, Locks L, Byrne D, et al. From service user to student—the benefits of recovery college. Clin Psychol Forum. 2015;268:32–7.
16.
Zurück zum Zitat Chien WT, Chan ZC. Chinese translation and validation of the questionnaire on the process of recovery in schizophrenia and other psychotic disorders. Res Nurs Health. 2013;36(4):400–11.PubMedCrossRef Chien WT, Chan ZC. Chinese translation and validation of the questionnaire on the process of recovery in schizophrenia and other psychotic disorders. Res Nurs Health. 2013;36(4):400–11.PubMedCrossRef
17.
Zurück zum Zitat Kasai K, Ando S, Kanehara A, Kumakura Y, Kondo S, Fukuda M, Kawakami N, Higuchi T: Community mental health services in Japan need strengthening. Lancet Psychiatry, in press. Kasai K, Ando S, Kanehara A, Kumakura Y, Kondo S, Fukuda M, Kawakami N, Higuchi T: Community mental health services in Japan need strengthening. Lancet Psychiatry, in press.
21.
Zurück zum Zitat Ogawa K, Miya M, Watarai A, Nakazawa M, Yuasa S, Utena HA. Long-term follow-up study of schizophrenia in Japan--with special reference to the course of social adjustment. Br J Psychiatry. 1987;151:758–65.PubMedCrossRef Ogawa K, Miya M, Watarai A, Nakazawa M, Yuasa S, Utena HA. Long-term follow-up study of schizophrenia in Japan--with special reference to the course of social adjustment. Br J Psychiatry. 1987;151:758–65.PubMedCrossRef
22.
Zurück zum Zitat Wild D, Grove A, Martin M, Eremenco S, McElroy S, Verjee-Lorenz A, et al. Principles of good practice for the translation and cultural adaptation process for patient-reported outcomes (PRO) measures: report of the ISPOR task force for translation and cultural adaptation. Value Health. 2005;8(2):94–104.PubMedCrossRef Wild D, Grove A, Martin M, Eremenco S, McElroy S, Verjee-Lorenz A, et al. Principles of good practice for the translation and cultural adaptation process for patient-reported outcomes (PRO) measures: report of the ISPOR task force for translation and cultural adaptation. Value Health. 2005;8(2):94–104.PubMedCrossRef
23.
Zurück zum Zitat Corrigan P, Giffort D, Rashid F, Leary M, Okeke I. Recovery as a psychological construct. Community Ment Health J. 1999;35:231–9.PubMedCrossRef Corrigan P, Giffort D, Rashid F, Leary M, Okeke I. Recovery as a psychological construct. Community Ment Health J. 1999;35:231–9.PubMedCrossRef
24.
Zurück zum Zitat Chiba R, Miyamoto Y, Kawakami N. Reliability and validity of the Japanese version of the recovery assessment scale (RAS) for people with chronic mental illness: scale development. Int J Nurs Stud. 2010;47(3):314–22.PubMedCrossRef Chiba R, Miyamoto Y, Kawakami N. Reliability and validity of the Japanese version of the recovery assessment scale (RAS) for people with chronic mental illness: scale development. Int J Nurs Stud. 2010;47(3):314–22.PubMedCrossRef
25.
Zurück zum Zitat Ware J, Kosinski M, Dewey J, Gandek B. How to score and interpret single-item health status measures: a manual for users of the SF-8 health survey. Boston: QualyMetric; 2001. Ware J, Kosinski M, Dewey J, Gandek B. How to score and interpret single-item health status measures: a manual for users of the SF-8 health survey. Boston: QualyMetric; 2001.
26.
Zurück zum Zitat Fukuhara S, Suzukamo Y. Manual of the SF-8 Japanese version. Institute for Health Outcomes & Process Evaluation Research: Kyoto; 2004. Fukuhara S, Suzukamo Y. Manual of the SF-8 Japanese version. Institute for Health Outcomes & Process Evaluation Research: Kyoto; 2004.
27.
Zurück zum Zitat Bartko JJ. The intraclass correlation coefficient as a measure of reliability. Psychol Rep. 1996;19(1):3–11.CrossRef Bartko JJ. The intraclass correlation coefficient as a measure of reliability. Psychol Rep. 1996;19(1):3–11.CrossRef
29.
Zurück zum Zitat Cortina JM. What is coefficient alpha? An examination of theory and applications. J Appl Psychol. 1993;78(1):98.CrossRef Cortina JM. What is coefficient alpha? An examination of theory and applications. J Appl Psychol. 1993;78(1):98.CrossRef
30.
Zurück zum Zitat Hair JF Jr, Black WC, Babin BJ, Anderson RE. Multivariate data analysis. 7th ed. Upper Saddle River NJ: Prentice Hall; 2010. Hair JF Jr, Black WC, Babin BJ, Anderson RE. Multivariate data analysis. 7th ed. Upper Saddle River NJ: Prentice Hall; 2010.
31.
Zurück zum Zitat Nunnally JC, Bernstein I. Psychometric theory. 3. New York: McGraw-Hill; 1994. Nunnally JC, Bernstein I. Psychometric theory. 3. New York: McGraw-Hill; 1994.
32.
Zurück zum Zitat Schreiber JB. Core reporting practices in structural equation modeling. Res Social Adm Pharm. 2008;4(2):83–97.PubMedCrossRef Schreiber JB. Core reporting practices in structural equation modeling. Res Social Adm Pharm. 2008;4(2):83–97.PubMedCrossRef
33.
Zurück zum Zitat Fabrigar LR, Wegener DT, MacCallum RC, Strahan EJ. Evaluating the use of exploratory factor analysis in psychological research. Psychol Methods. 1999;4:272–99.CrossRef Fabrigar LR, Wegener DT, MacCallum RC, Strahan EJ. Evaluating the use of exploratory factor analysis in psychological research. Psychol Methods. 1999;4:272–99.CrossRef
34.
Zurück zum Zitat Argentzell E, Hultqvist J, Neil S, Eklund M. Measuring personal recovery - psychometric properties of the Swedish questionnaire about the process of recovery (QPR-Swed). Nord J Psychiatry. 2017;71(7):529–35.PubMedCrossRef Argentzell E, Hultqvist J, Neil S, Eklund M. Measuring personal recovery - psychometric properties of the Swedish questionnaire about the process of recovery (QPR-Swed). Nord J Psychiatry. 2017;71(7):529–35.PubMedCrossRef
35.
Zurück zum Zitat Kitayama S, Karasawa M, Curhan KB, Ryff CD, Markus HR. Independence and interdependence predict health and wellbeing: divergent patterns in the United States and Japan. Front Psychol. 2010;2(1):163. Kitayama S, Karasawa M, Curhan KB, Ryff CD, Markus HR. Independence and interdependence predict health and wellbeing: divergent patterns in the United States and Japan. Front Psychol. 2010;2(1):163.
36.
Zurück zum Zitat Tse S, Ng R. Applying a mental health recovery approach for people from diverse backgrounds: the case of collectivism and individualism paradigms. J Psychosoc Rehabil Ment Health. 2014;1(1):7–13.CrossRef Tse S, Ng R. Applying a mental health recovery approach for people from diverse backgrounds: the case of collectivism and individualism paradigms. J Psychosoc Rehabil Ment Health. 2014;1(1):7–13.CrossRef
37.
Zurück zum Zitat Slade M, Leamy M, Bacon F, Janosik M, Le Boutillier C, Williams J, et al. International differences in understanding recovery: systematic review. Epidemiol Psychiatr Sci. 2012;21(4):353–64.PubMedCrossRef Slade M, Leamy M, Bacon F, Janosik M, Le Boutillier C, Williams J, et al. International differences in understanding recovery: systematic review. Epidemiol Psychiatr Sci. 2012;21(4):353–64.PubMedCrossRef
38.
Zurück zum Zitat Fukui S, Shimizu Y, Rapp CA. A cross-cultural study of recovery for people with psychiatric disabilities between US and Japan. Community Ment Health J. 2012;48(6):804–12.PubMedCrossRef Fukui S, Shimizu Y, Rapp CA. A cross-cultural study of recovery for people with psychiatric disabilities between US and Japan. Community Ment Health J. 2012;48(6):804–12.PubMedCrossRef
39.
Zurück zum Zitat Kitayama S, Karasawa M, Curhan KB, Ryff CD, Markus HR. Independence and interdependence predict health and wellbeing: divergent patterns in the United States and Japan. Front Psychol 2010;2. 1:163. Kitayama S, Karasawa M, Curhan KB, Ryff CD, Markus HR. Independence and interdependence predict health and wellbeing: divergent patterns in the United States and Japan. Front Psychol 2010;2. 1:163.
40.
Zurück zum Zitat Hofer A, Mizuno Y, Frajo-Apor B, Kemmler G, Suzuki T, Pardeller S, et al. Resilience, internalized stigma, self-esteem, and hopelessness among people with schizophrenia: cultural comparison in Austria and Japan. Schizophr Res. 2016;171(1–3):86–91.PubMedCrossRef Hofer A, Mizuno Y, Frajo-Apor B, Kemmler G, Suzuki T, Pardeller S, et al. Resilience, internalized stigma, self-esteem, and hopelessness among people with schizophrenia: cultural comparison in Austria and Japan. Schizophr Res. 2016;171(1–3):86–91.PubMedCrossRef
Metadaten
Titel
The Japanese version of the questionnaire about the process of recovery: development and validity and reliability testing
verfasst von
Akiko Kanehara
Risa Kotake
Yuki Miyamoto
Yousuke Kumakura
Kentaro Morita
Tomoko Ishiura
Kimiko Shimizu
Yumiko Fujieda
Shuntaro Ando
Shinsuke Kondo
Kiyoto Kasai
Publikationsdatum
01.12.2017
Verlag
BioMed Central
Erschienen in
BMC Psychiatry / Ausgabe 1/2017
Elektronische ISSN: 1471-244X
DOI
https://doi.org/10.1186/s12888-017-1520-y

Weitere Artikel der Ausgabe 1/2017

BMC Psychiatry 1/2017 Zur Ausgabe