The Turkish Journal of Pediatrics
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Validation and Reliability Study of the Turkish Version
of the Pediatric Rhinitis Quality of Life Questionnaire
Hasan Yüksel1, Özge Yılmaz1, Ayhan Söğüt1, Erhan Eser2
Departments of 1Pediatric Allergy and Pulmonology, and 2Public Health, Celal Bayar University Faculty of Medicine,
|The aim of this study was to develop a Turkish version of the Turkish
Pediatric Rhinitis Quality of Life Questionnaire (PRQLQ) that is conceptually
equivalent to the original and to evaluate its validity and reliability.
The study included 102 children with allergic rhinitis (AR) aged 5 to 16
years. Demographic information, family history of allergy, and duration of AR
were recorded. All patients completed the T4SS symptom score and PRQLQ.
Reliability including internal consistency and item–total score correlations and
validity analysis including Known Group method were performed.
Activity limitations, emotional function and symptoms domains had successful
Cronbach alpha scores of 0.62, 0.69 and 0.78, respectively. All items were
significantly correlated with their own domain. Correlations of all the domain
scores with the total score and the other domains were significant. Linear
multiple regression reduced models revealed that both domain and total
scores showed statistically significant sensitivity to T4SS.
The Turkish PRQLQ is a valid and reliable measure for use in Turkish
children with AR.
allergic rhinoconjunctivitis, health-related quality of life, Pediatric Rhinitis
Quality of Life Questionnaire, children.
|Health is the “state of complete physical,
mental and social well-being” according to the
description of the World Health Organization.
This description brings in a general concept that
is broader than absence of disease. Therefore,
not only the biological but also psychosocial
state of an individual needs to be considered in
the context of health1. The concept of healthrelated
quality of life (HRQL) evolved on this
basis. HRQL measures are mainly categorized
into either generic measures that evaluate
different aspects of quality of life in all health
conditions but are insensitive to specific effects
of a particular disease condition2,3, or diseasespecific
HRQL measures that are designed to
measure the influence of a specific disease
condition and are more sensitive,.
Chronic diseases during childhood impair
quality of life to a great extent, and allergic
diseases are the most common chronic diseases
of childhood1. Allergic rhinitis (AR) is the most
common allergic disease with a worldwide
prevalence of 5-40% and with clinical findings
characterized by nasal itching, sneezing,
rhinorrhea, nasal congestion, and conjunctival
symptoms5-8. AR impairs HRQL in patients
due to many aspects of disease like nasal
itching, sneezing, need to carry tissue paper,
etc.; however, there are other aspects of the
disease that need to be considered in pediatric
patients9,10. These include the impact on school
life in the form of learning disabilities and
school absenteeism and the impact on social
life like inability to fully interact with peers in
play9,11. Moreover, the disease may also affect
the family who may become overprotective,
constraining the child’s life to a greater extent
and who may themselves miss work,.
The essence of evaluation of HRQLQ in
children with AR is obvious from the above
data and an English questionnaire exists12.
However, a Turkish questionnaire was lacking.
Therefore, the aim of the present study was
to develop a Turkish version of the Pediatric
Rhinitis Quality of Life Questionnaire (PRQLQ)
that can be understood by the patients while
keeping conceptual equivalence with the
original and to evaluate its validity, internal
consistency and reliability.
|Material and Methods |
Subjects and Study Design
The study included 102 children with AR who
presented to Celal Bayar University Medical
Faculty, Department of Pediatric Allergy and
Pulmonology consecutively. Clinical findings
of nasal itching, sneezing, nasal congestion,
and rhinorrhea prompted the diagnosis of
intermittent AR. Upon recruitment into the
study, demographic information regarding age,
sex, education and family history of allergic
diseases was recorded, together with duration
of AR. All patients were asked to complete
the T4SS symptom score to evaluate disease
severity and the Turkish PRQLQ.
The Pediatric Rhinitis Quality of
The PRQLQ was developed by Juniper et
al.12 and published in 1998. It is composed
of symptoms, emotional function and activity
limitations domains, with a total of 23
questions. Each item has Likert-type scales
of seven-point responses that range from 0 to
6. All items are equally weighted and higher
scores show worse outcome. Domains and total
scores are the mean of the items included.
“Symptoms” domain includes items 4, 6, 8, 10,
12, 14, 16, 18, 20, 23, “emotional function”
domain includes 5, 7, 9, 11, 13, 15, 17, 21 and
“activity limitations” domain includes items 1,
2, 3, 19, and 22.
Adaptation into Turkish
Adaptation of the PRQLQ into Turkish was
performed in four steps.
1. Forward translations: Two independent
translators who are native speakers of Turkish
translated the measure into Turkish.
2. Consensus forward translation: The two
translations were revised by the translators
and two other pediatricians and one measure
was achieved that was agreed upon by all.
3. Back translations: The Turkish PRQLQ was
translated back into English by two independent
translators. The English back translation
was checked by original developers of the
questionnaire and a conceptual equivalence
with the original questionnaire was achieved
by minor rewording.
4. Cognitive debriefing: Ten children with
AR were given the questionnaire and were
asked about the ease of comprehension and
to suggest alternatives if any item was found
to be incomprehensible.
T4SS is used to assess symptom severity in
patients with AR. It includes nasal itching,
ocular itching, sneezing, and nasal discharge
that are scored by the patients themselves
from 0 to 3 with increasing severity. Scores
for all domains are summed up to obtain the
Reliability and validity analyses were performed
using the SPSS 10.0 statistical package.
Reliability analysis included internal consistency
and item–total score correlations. Cronbach alpha
coefficient was calculated for every sub-scale of
the instrument to evaluate internal consistency.
Correlations of each item and total score were
assessed by Spearman correlation analysis.
Construct validity analysis was performed by
the Known Group method. The test was found
to have high sensitivity to changes in T4SS as
a marker of disease severity. Known Groups
Validity was tested by ANOVA and multiple
This study included 102 children (71 male, 31
female) aged between 5 and 16 years (mean±SD:
1.2±2.9 years). Family history revealed history of an
allergic disease in 46.1% of the children (Table I).
Reported duration of disease ranged between 1 to
10 years (mean±SD: 2.5±1.8 years).
The Internal Consistency of the PAQLQ was
tested by Cronbach alpha scores and item-total
correlations. Activity limitations, emotional function and symptoms domains had successful
Cronbach alpha scores of 0.62, 0.69 and 0.78,
respectively (Table II).
Correlation of each item with its respective
domain score revealed that all the items were
significantly correlated with their own domain.
| ||Table I. Sociodemographic Properties of the
| ||Table II. Internal Consistency of the PRQLQ
(Cronbach alpha values)|
Correlation coefficients for item versus domain
score correlation ranged between 0.38 and 0.70
for activity, 0.41 and 0.65 for symptoms and
0.29 and 0.70 for emotional function domains
When success of the item discriminant validity
tests was summarized, it was found that 80%,
90% and 100% of the items included in the
activity limitations, symptoms and emotional
function domains, respectively, were highly
correlated with their own scale (Table IV).
Correlation of all the domain scores with
the total score and the other domains was
significant. Coefficients for the correlation
of the total score with the domains ranged
between 0.72 and 0.94. Coefficients for the
correlation of the domains with each other
ranged between 0.57 and 0.79 (Table V).
Validity of the PRQLQ was tested with Known
Groups validity. Comparison of the PRQLQ
domain and total scores among the three groups
of T4SS values as (<6, 7-11, >12) revealed
that the scores were significantly higher in the
group with higher T4SS (Table VI).
Moreover, linear multiple regression reduced
models indicating effects of age, duration of
disease and T4SS on the domain and total
scores of PRQLQ revealed that both domain
and total scores showed statistically significant
sensitivity to T4SS (Table VII).
|Health-related quality of life (HRQL) is a
subjective and multidimensional concept that
includes a patient’s perception of health, disease
and its impact on life and functioning,.
Therefore, evaluation of HRQL needs to include
a subjective measure of the multiple dimensions
of life. It is an important measure of outcome
because the impact of any disease differs on a
personal basis due to perceptual differences of
each individual for symptoms and severity of
disease. Generic measures of HRQL can be
used in all individuals and lack specificity3,4.
They are important for their use in comparing
the HRQL impact of different diseases as well
as to compare the impact of a disease with
the healthy population3,4,9. However, these
measures are insensitive to specific effects of
a particular disease condition on the patient.
| ||Table III. Item Descriptive Results and Item-Scale Correlations*|
| ||Table IV. Success (%) Summary for Item Discriminant Validity Tests|
| ||Table V. Inter-Correlations* Between the Sub-Scales of the PRQLQ|
| ||Table VI. Sensitivity of the Sub-Scale and Overall PRQLQ Score to the Variability of the T4SS Score|
| ||Table VII. Results of the Linear Multiple Regression Reduced Models Indicating the Effects of Age, Duration of Illness and T4SS on the Three
Domain and Total Scores of the PRQLQ|
Awareness of this has led to the development of
disease-specific HRQL measures3. The PRQLQ
was developed by Juniper et al.12 for use in
children aged 6 to 12 years with intermittent
AR, and the validation study published in 1998
revealed that it is a reliable measure of HRQL
in these children.
Evaluation of HRQL is a difficult task in
children because the child’s age, familial
interactions and language comprehension need
to be considered4. Children’s perception of
disease and its impact and lifestyle is quite
different from adults1. Moreover, they may
have difficulty understanding the questions
and the timeframes that are referenced1.
Therefore, development and evaluation of
pediatric HRQL questionnaires require a
more thorough understanding of HRQL and
the pediatric view and they require extensive
refinement. Considering this, the adaptation
of the PRQLQ into Turkish was performed
in four steps to achieve the comprehension
of Turkish children while keeping the items
as close to the original as possible. The four
steps included two independent translations by
bilingual translators, which were revised into
one final translation by the translators and
two pediatricians. The third step included back
translation into English, which was checked
by the original developers. The last stage was
cognitive debriefing with 10 children with
AR. This last step was important to ensure
comprehension by Turkish children because
use of HRQL questionnaires in populations
with a native language that is different from
the language of development requires a crosscultural
adaptation and revalidation15.
Allergic rhinoconjunctivitis in children is
expected to decrease quality of life of both
parents and children in an interacting way.
Considering all these factors, it is not surprising
to expect that the presence or absence
of symptoms differs from HRQL because
every patient has a different way of life and
expectations that are affected to a different
extent by the same symptom12. Recently, it
was considered that evaluation of AR requires
assessment of not only symptoms but also
functional, emotional and psycho-social effects
of the disease2. It has been reported that
quality of life in patients with AR correlated
significantly with patients’ subjective report
of symptom severity; however, this kind of a correlation was lacking with endoscopic
findings16. The results of this validation study
revealed that there was a significant correlation
between T4SS scores and all domains as well as
the total PRQLQ scores. When it is considered
that both require subjective evaluation of
disease, this is an expected finding that reflects
the sensitivity of the Turkish version of the
PRQLQ to disease severity. This demonstrated
that the Turkish PRQLQ can measure what
it proposes to measure, in other words, the
validity of the PRQLQ.
Reliability is used to describe the stability of a
measure17. Internal consistency and Cronbach
reliability analysis of the Turkish PRQLQ were
found to be adequate in this study. The only
two questions that had high Cronbach alpha
values in item analysis were questions 13 and
22. However, we found that their correlation
with their own domains was higher than the
other two domains so they were not regarded
as problematic questions.
Disease-specific questionnaires are more
sensitive to changes over time and are used
mostly to compare the effect of treatment4.
However, in this study, change over time with
treatment was not measured. This represents
the main limitation of the study.
In conclusion, since health is described
as a complete state of well-being, disease
evaluation needs to include physical, social and
psychological aspects of the individual. Physical
evaluation is managed in different aspects by
every physician in charge. However, assessment
of HRQL requires a valid and reliable measure
in the native language of the patient. This study
has demonstrated that the Turkish PRQLQ is
a valid and reliable measure for use in Turkish
children with AR.
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