The WHOQOL-BREF is a 26 item brief version of the WHOQOL questionnaire. The WHOQOL-BREF covers four individual domains such as: Physical (activities of daily living, dependence on medicinal substances and medical aids, energy and fatigue, mobility, pain and discomfort, sleep and rest, work capacity); Physiological (bodily image and appearance, negative feelings, positive feelings, self-esteem, spirituality /religion/personal beliefs, thinking, learning, memory and concentration); Social (personal relationships, social support, sexual), and Environmental (financial resources, freedom/physical safety and security, health and social care: accessibility and quality, home environment, opportunities for acquiring new information and skills, participation in and opportunities for recreation/ leisure activities physical environment (pollution/ noise/ traffic / climate/ issues. Higher WHOQOL-BREF scale scores indicate better quality of life.
Afghanistan is a multi-ethnic country with Pashtuns, Tajiks, Uzbeks and Hazaras making up the majority of the population although Dari is one of the languages mostly used by the people of Herat city in Afghanistan and most of them are comfortable with Dari language.
Linguistic And Cultural Adaptation:
The cultural adaptation of the WHOQOL-BREF into Dari has consisted of two stages: translation stage, and the cognitive debriefing (pilot) stage following the translation stage. The process of translation of WHOQOL-BREF included recommended methodology, mandating forward translation, backward translation was followed. Forward translations were done by four independent translators and a consensus Dari version was developed by an expert linguist. The back translation of the Dari consensus version of the WHOQOL-BREF into English was done by a bilingual person. The back translated text was then compared with the original English version of the WHOQOL-BREF and a careful comparison was done between the two texts in terms of conceptual inconsistencies. When any inconsistency is detected between the two texts, the Dari version was revised accordingly, following a panel discussion with the translators.
Cognitive debriefing interviews were carried out on 30 healthy individuals. Following the completion of the questionnaire, each individual was asked to give their feedback about each of the items and response scales of the WHOQOL-BREF and each of the instruction sentences of the instrument. They were asked to tell:
" Whether they were able to understand each of the items and each of the instruction sentences or not?"
"If there is any word or phrase that they did not understand" if so, "how would they rephrase the question or the sentence?"
They were also asked to do Thurston sort card exercise to confirm the correct order of response options in Dari version. It took almost 10 minutes for each individual to complete the questionnaire. The volunteers were able to understand all of the items and instructions with minimal modifications
Study Sample And Data Collection:
Field trial sample is a representative sample of Herat City, Afghanistan. The 2018 census of the Herat was around 270 000 (16) The number of households is around 45 000 in the city and the research was conducted on a household based stratified random sample of individuals aged 18 or above living in all 15 districts of Herat city. Volunteers consist of both healthy people (who stated that they are free of any kind of chronic disease) and ill participation (who stated that they have at least one or more medical condition receiving some form of medical care). Only one adult was selected from each of the households. 1473 persons were selected to the study sample (804 were males and 669 females). The gender imbalance was due to the higher willingness of men to participate to the study than women.
Of the participants, 53% were illiterate and 47% were literate. The inclusion criteria were being over age 18 and speaking the Dari language. Questionnaires were administered by an interviewer during face to face interviews in public.
Psychometric analyses of the filed data of the WHOQOL-BREF Dari version is consisted of distribution properties and item analyses followed by internal consistency and validity analyses. Minimal acceptable limits for Floor and Ceiling value percentages are ≤ 20% (17) and Skewness and Kurtosis limits are 2.0 (18).
Both reliability and Validity analysis were based on confirmatory approach. Internal consistency of the individual domains were tested by Cronbach's alpha (19) The average inter-item correlations for domains, and correlation of items with their intended domain were also calculated to assess scale success statistics. If Pearson’s product moment coefficients between the items and their own scale score (corrected for overlap) were higher than the correlations between these items and any other domain then its regarded that WHOQOL domains represent separate entities. "If item removed alpha values" and item scale correlations were used to detect any problematic items. If any domain's alpha value increases when internal consistency analyses in repeated when a certain item removed, then that item might be a problematic item. The problematic item may be proved by looking its correlation coefficient with its own dimension score if it is less than 0.30.
Convergent-divergent validity, known groups' validity and confirmatory factor analysis were employed for the assessment of construct validity of the WHOQOL-BREF Dari version. Sf-36 was used to test convergent-divergent validity of the WHOQOL-BREF and gender, education, social class and presence of any illness were used for known groups'/discriminant analyses. The discriminative ability of the instrument between a subgroups were assessed by Student’s t test indicating the known groups validity of the measurement. Effect size statistics (i.e. mean differences divided by pooled sd.) were computed to determine the magnitude of the difference in mean scores (20). A Cohen's D (ES) value closer to 0.20 indicates a small effect, whereas 0.50 a medium and 0.8 and over a big effect in two groups' comparisons. A third approach that was used in this manuscript for testing the construct validity of the WHOQOL-BREF-DARI was the Confirmatory Factor Analyses (CFA), type of Structural Equation Modelling. Fit indices generated by CFA were used to test the original WHOQOL scale structure of the Dari version of the WHOQOL-BREF. Root Mean Square Error Approximation (RMSEA) and Comparative Fit Index (CFI) Tucker Levis Index (TLI) and Root Mean Residuals (RMR) and Chi square tests. Critical acceptable threshold is 0.90 for CFI and TLI and 0.08 for RMSEA and RMR (18).
The construct validity of the measurement is examined by LISREL 8.5. Criterion validity was tested by linear regression analysis, taking general quality of item (q1) as the criterion of quality of life. Type 1 error is taken as 0.05 in all statistical analyses.