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Cross-Cultural Study of Quality of Life Indicators

Robert L. Schalock Hastings College Miguel Angel Verdugo and Christina Jenaro Universidad de Salamanca (Salamanca, Spain) Mian Wang Rowan University Mike Wehmeyer University of Kansas Xu Jiancheng Beijing Union University Yves Lachapelle University of Quebec-Trois-Rivieres

Abstract The concept of quality of life is increasingly being used internationally in the eld of intellectual disabilities. We surveyed three respondent groups representing ve geographical groupings on the importance and use of the 24 core quality of life indicators most commonly reported in the international quality of life literature. Results suggest (a) similar proles on importance and use across respondent and geographical groups, but differences in the frequency per response category; (b) signicant differences in mean quality of life importance and use scores for both respondent and geographic groupings; and (c) factors on importance and use generally grouped into eight core quality of life domains. Results are discussed in reference to the etic (universal) and emic (culture-bound) properties of the quality of life concept.

The concept of quality of life (QOL) is increasingly being used internationally in the eld of intellectual disabilities as a sensitizing notion, social construct, and overarching theme for planning, delivering, and evaluating individualized services and supports. Implied in its use is the belief that even though the perception of ones personal well-being is a subjective phenomenon, the QOL construct has utility at three systems levels: micro (individual), meso (agency, program), and macro (society, culture). At the micro-systems level, the QOL construct is being used as a basis for selfadvocacy, person-centered planning, and a valued person-referenced outcome from education and rehabilitation programs (Anderson & Burckhardt, 298

1999; Schalock et al., 2002; Schalock & Verdugo, 2002). At the meso-system level, it is being used for program planning, resource allocation, participatory action research, managing for results, and continuous program improvement (Schalock & Bonham, 2003). The QOL construct has also been studied from a cross-cultural perspective, with researchers focusing on issues related to conceptualization, measurement, and application of QOL across numerous countries and language groups. This crosscultural work is based on our increasing understanding of three phenomena: (a) the key role that culture plays in the expression of beliefs and behaviors, (b) the identication of core domains and American Association on Mental Retardation

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indicators of personal well-being (i.e., QOL), and (c) the nding that the QOL construct has similar meaning (i.e., etic properties) across numerous countries and language groups (Keith & Schalock, 2000; Schalock & Verdugo, 2002; Skevinton, 2002). The importance of cross-cultural studies is that they can provide theoretical insights into whether QOL is a universal or relativistic concept and the degree of its importance and use, both between and within geographical and respondent groups (Saxena, Carlson, Billington, & Orley, 2001), and the best measurement approach to use (Herdman, Fox-Rushby, & Badia, 1997). In cross-cultural research, reference is made to the etic (universal) and emic (culture-bound) properties of a construct or phenomenon. The etic/ universal property of the QOL construct has been demonstrated in studies in which investigators have reported (a) similar scores on the value dimension of key QOL concepts (Keith, Heal, & Schalock, 1996); (b) an increase in QOL scores associated with more normalized working and living environments (Schalock et al., 1990); and (c) similar factor structure in QOL measures, such as the Schalock and Keith (1993) Quality of Life Questionnaire (Kober & Eggleton, 2002; Rapley & Lobley, 1995; Verdugo, Prieto, Caballo, & Pelaez, in press). The emic/culture-bound property of the construct is reected in (a) slightly different cross-nation ratings on the potency and activity dimensions of the QOL construct (Heal, 1996; Keith et al., 1996), (b) less than perfect factor stability in cross-cultural QOL measurement (Kober & Eggleton, 2002), and (c) geographical differences in the application of the QOL construct (Keith & Schalock, 2000). Although these studies suggest the existence of etic and emic properties of the QOL construct, a clear understanding of the cross-cultural nature of the construct has been hampered by different concepts being rated across studies and a lack of literature-based core QOL domains and indicators (Bullinger, Anderson, Cella, & Aaronson, 1993; Schalock, 2004; Tapsoba, Deschamps, & Leclercq, 2000). A recent synthesis of the international QOL literature (Schalock & Verdugo, 2002) in the four focus areas of education (regular and special), health (physical and mental/behavioral), intellectual disabilities/mental retardation, and aging suggest strongly that a life of quality is composed of eight core domains. These eight, along with the three most commonly referenced published indicators for each domain, are listed in Table 1. The American Association on Mental Retardation

number preceding each indicator refers to the survey item number used in the present study. We conducted this study within the context of the cross-cultural studies referenced above and the core QOL domains and indicators listed in Table 1. Our three primary purposes were to determine (a) the etic/universal and emic/culturebound properties of the QOL construct, (b) ratings of the relative subjective importance and use of the core QOL indicators listed in Table 1, and (c) whether these measures are reasonably stable across respondent and geographical groups. We assessed the importance and use of the 24 indicators shown across ve geographical areas (geographical groups) and three respondent groups. Three hypotheses were tested: (a) the etic properties of the QOL construct would be demonstrated if there were similar proles on importance and use for the respondent and geographical groups, (b) the emic properties of the QOL construct would be demonstrated if there were signicant differences in mean importance and/or use scores for the respondent and the geographical groups, and (c) the clusters and factors on importance and use are grouped into the eight QOL domains listed in Table 1. An alpha level of .01 was used in all analyses. The study involved ve geographical groups (Spain, Central/South America, Canada, Mainland China, and the United States) and three respondent groups (consumers, parents, and professionals) who rated both the importance and use of each of the 24 QOL core indicators listed in Table 1. The rating was done within the context of the respondents country, with a focus on the services/supports received or delivered to persons with intellectual disabilities. Geographical groupings included people from three continents and four world regions (North America, Central/ South America, Europe, Asia) with different cultural and social characteristics and different languages. Central and South American countries were grouped together because they share a common language (Spanish) and culture (Latin), and collaborate in political, economic, and cultural affairs.

Method Participants
Data were collected in ve geographical areas: Latin America (46.4% of total sample), Spain (22.8%), China (18.8%), Canada (6.8 %), and the 299

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Table 1. Core Quality of Life Domains and Most Commonly Used Indicators
Domain Emotional Well-Being Indicators, descriptors, and survey item 1. Contentment (satisfaction, moods, enjoyment) 2. Self-concept (identify, self-worth, self-esteem) 3. Lack of stress (predictability and control) 4. Interactions (social networks, social contacts) 5. Relationships (family, friends, peers) 6. Supports (emotional, physical, nancial) 7. Financial status (income, benets) 8. Employment (work status, work environment) 9. Housing (type of residence, ownership) 10. Education (achievements, education status) 11. Personal competence (cognitive, social, practical) 12. Performance (success, achievement, productivity) 13. Health (functioning, symptoms, tness, nutrition) 14. Activities of daily living (self-care, mobility) 15. Health care 16. Leisure (recreation, hobbies) 17. Autonomy/personal control (independence) 18. Goals and personal values (desires, expectations) 19. Choices (opportunities, options, preferences) 20. Community integration and participation 21. Community roles (contributor, volunteer) 22. Social supports (support networks, services) 23. Human (respect, dignity, equality) 24. Legal (citizenship, access, due process)

Interpersonal Relations

Material Well-Being

Personal Development

Physical Well-Being

Self-Determination

Social Inclusion

Rights

United States (5.2%). The respondent group was composed of 2,042 individuals. Of this total, 778 were consumers (38.1% of the sample, 38.7% female, 61.3% male), 491 families (24% of sample, 75.6% female, 24.4% male), and 773 professionals (37.9% of sample, 26.2% female, 73.8% male). The average age of the consumer was 35 years. All consumers had a diagnosis of mental retardation (intelligence tests and adaptive behavior instruments are not universally used) and could be considered within the mild/moderate range of intellectual functioning. All were self-respondents (oral or written). The majority (53.2%) received services within the public service sector. Service environments included regular employment (4.3%), sheltered workshop (9.3%), supported employment (11.3%), occupation center (48.4%), and other (26.7%). The majority of consumers (83.6%) lived with their family, with 6.6% living independently, 5.2% in supported living, and 4.6% in a care facility. Professionals were psychologists, direct care staff members, or special ed300

ucation teachers (who typically work with adults in many countries). The majority (57.3%) worked in the public sector. Most (49.4%) had been working in the eld for 10 years or longer, with 8.9% under one year; 25%, 1 to 5 years; and 16.7%, 5 to 10 years. The primary focus of the services/ supports provided was employment (19.3%), education (65.8%), care (10.2%), or community living (4.7%).

Survey Instrument
The survey instrument was based on the 24 core indicators listed in Table 1. For each indicator, two sets of questions were asked related to the indicators importance and use: (a) How important is it (the indicator) for you (consumer), people with intellectual disabilities (family), or people with intellectual disabilities in your country (professional)? and (b) To what degree do (the facility/service) take people who work at it (the core indicator) in mind (consumer); how much is it used in services/supports received (fam American Association on Mental Retardation

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ily); or how much is it used in services/supports received or delivered (professional)? A 4-point Likert scale was used to measure the response dimensions for both sets of questions: Importance: not important at all (1), not very important (2), somewhat important (3), and very important (4); and Use: never (1), sometimes (2), frequently (3), always (4). In terms of format, page 1 of the survey included a brief overview of the study and its purpose; directions for answering the questions; spaces for respondent characteristics to be written in; boxes to be checked as to location of services, work, and living environments; and denitions with examples of the eight core QOL domains. For the consumer form, directions were expanded, with frequent prompts regarding whether or not the person understood the directions. Subsequent pages (5 on the consumer form due to additional directions and prompts; 3 each for family and professional forms) listed the 24 indicators (which were listed adjacent to the respective core domain). Respondents were asked to circle 1, 2, 3, or 4 for each indicator. If necessary, each question was read orally to the consumer, with frequent prompts given, such as Do you understand and/ or do you need further clarication or an example? The 4-point scale (with associated rating descriptions) was reproduced on the top of each page to ensure understanding of the rating scale to be used and, hence, increase the instruments reliability. Two types of reliability were established on the importance ratings: Cronbachs internal consistency (alpha) and split-half. Cronbachs alpha coefcients ranged from .92 to .95 and averaged .94 (standard deviation [SD] .01); splithalf coefcients ranged from .84 to .92 and averaged .89 (SD .03). These reliability coefcients indicate good reliability for the survey instrument.

Procedure
Cross-cultural research involves at least four procedural challenges related to translation, participant recruitment, data collection, and data analysis. We attempted to overcome these challenges through the following procedures. Translation. The survey instrument was developed initially in English and then translated into Spanish and Mandarin. Two types of equivalence were the focus in the instruments translation: conceptual (or content) equivalence through the use of a panel rating process (Shin, 2002) and linguistic (or semantic) equivalence using back-trans American Association on Mental Retardation

lation techniques (Brislin, 1986; Herdman et al., 1997; Liang & Bogat, 1994; Tapsoba & Craig, 1999). A three-step translation process was used. First, two bilingual professionals (psychologist or special education teacher) translated the English version into the respective language (Spanish or Mandarin). Second, two other bilingual professionals translated the Spanish and Mandarin version back into English. Third, the total group (four persons) checked the translation and rectied any discrepancies found by consulting with one or more of the authors. Country-specic peculiarities were considered during the entire translation process. Participant recruitment. Neither random nor purposeful sampling was employed in the study. Rather, the general procedure was for each of the authors to contact colleagues (especially service providers and professionals in the eld of intellectual disabilities/mental retardation) and elicit their support for the study and their willingness to recruit three sets of respondents: consumers, parents, and professionals. The criterion used was that parent respondents be the parent of the respective consumer respondent and that the professional (generally direct care staff or special education teacher) be familiar with the consumer and the services and supports they received. Most participants were recruited from geographically dispersed urban areas within the respective country, but in Mainland China the participants were recruited from four cities only (Beijing, Chongqing, Harbin, and Ningbo, which represented central, east, north, and west China). In each case, the study was described along with its purpose. The authors claried with the colleaguerecruiter instructions regarding completion of the survey instrument and directions as to time lines, how to verify the data, and the need for complete information. The colleaguerecruiter then selected available data-collection sites and potential respondents. Data collection. Data were collected within the persons home, school, residential environment, occupation center, or workplace by direct care staff members, special education teachers, or psychologists. The study, survey form, and survey procedure were described by the colleaguerecruiter to each data collector, along with the essential need to be consistent in their administration of the instrument, but responsive to the respondent by clarifying any words or terms used in the survey. The need to follow the stated pro301

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cedures was stressed repeatedly. In addition, a Web page was opened and two of the authors were available to answer any questions raised by the contact colleague or survey administrator. There was no time limit imposed for completing the survey. The procedure used precluded the tracking of the number of consumers and parents who refused the invitation to participate in the survey. Completed surveys were returned to the data collector, who in turn sent them in batches to the author/contact person. Completed surveys were then sent to the Institute on Community Integration (Salamanca, Spain) for compilation and analysis. Upon receipt, we veried each survey form for completeness, with the data entered into a SPSS spread sheet. The SPSSx statistical package for social sciences (SPSS, 1998) was used for all analyses. Data analysis. Cross-cultural research poses two important issues regarding data analysis. The rst relates to testing the construct to ensure comparability across cultures/language groups (i.e., its

etic properties). The second issue relates to testing for a social, culture-specic component that reects cultural/language group differences (i.e., its emic properties). We used three analyses to evaluate the constructs etic and emic properties: (a) response prole analysis for importance and use scores, (b) analysis of variance of the mean importance and use scores, and (c) exploratory factor analysis of the QOL domain scores.

Results: Importance Ratings Response Prole Analysis

The average scores on importance across geographical areas and respondent groups show a general skewedness, with mean scores higher than 3 on importance for each of the countries and groups, with the exception of mean scores on SelfDetermination for Chinese families and social inclusion for Chinese users (see Table 2). These results provide strong evidence for cross-cultural universality of the proles of responses to individ-

Table 2. Means on Importance by Participant and Geographic Groups

Group/Geographic area Professionals Spain Latin-America USA Canada China Total Users Spain Latin-America USA Canada China Total Families Spain Latin-America USA Canada China Total 1 3.73 3.69 3.53 3.53 3.14 3.53 3.81 3.66 3.88 3.83 3.16 3.66 3.61 3.80 3.81 3.54 3.11 3.68 2 3.70 3.69 3.47 3.49 3.27 3.55 3.85 3.67 3.70 3.79 3.17 3.67 3.70 3.77 3.81 3.54 3.31 3.70 3 3.49 3.45 3.48 3.36 3.21 3.39 3.82 3.67 3.80 3.77 3.08 3.65 3.45 3.61 3.77 3.43 3.15 3.53 4 3.43 3.58 3.25 2.96 3.17 3.37 3.80 3.64 3.64 3.72 3.15 3.63 3.37 3.70 3.36 3.23 3.11 3.54 5 3.64 3.66 3.63 3.40 3.44 3.57 3.89 3.75 3.79 3.83 3.29 3.74 3.52 3.83 3.79 3.77 3.30 3.72 6 3.51 3.49 3.51 3.21 3.00 3.34 3.65 3.61 3.76 3.71 3.04 3.56 3.10 3.62 3.56 3.49 2.97 3.46 7 3.57 3.63 3.38 3.28 3.11 3.44 3.66 3.46 3.46 3.67 2.97 3.47 3.38 3.66 3.54 3.55 3.13 3.54 8 3.64 3.76 3.59 3.16 3.41 3.58 3.87 3.74 3.78 3.82 3.22 3.72 3.51 3.81 3.68 3.67 3.26 3.68

Note. 1 Emotional Well-Being, 2 Interpersonal Relations, 3 Material Well-Being, 4 Personal Development, 5 Physical Well-Being, 6 Self-Determination, 7 Social Inclusion, 8 Rights.

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ual items, given that mean scores are similar across geographical areas and respondent groups. Nevertheless, when computing percentages of responses 1 to 4 on importance across geographical groups, we obtained a signicant association between geographical groups and rating values. As shown in Table 3, the response distribution across geographical groups of importance based on the percentage of respondents indicating scores of 1 (not important at all) to 4 (very important) showed a signicant association between geographical groups and rating values, 2(12) 3756.68, p .01. This nding, based on calculating the Pearson chi-square and the likelihood ratio chi-square, suggests that living in different countries affects the judgments on importance.

Factor Analysis
An exploratory factor analysis was performed to identify the factors that explain most of the variance observed. The 24 items on importance were included in the analysis. We employed principal components analysis method of extraction, collapsing over respondent and geographical groups. A priori selection of eight factors to extract was established, in order to explore the viability of the theoretical model (i.e., the eight QOL domains). Communalities ranged from .56 (Item 16) to .82 (Item 24). Initial eigenvalues ranged from 10.19 (Factor 1) to .65 (Factor 8), with a cumulative percentage of 68.34. The eight-factors solution grouped the 24 variables as follows: (a) Self-Determination and Social Inclusion (Items 17 to 22), (b) Physical Well-being (Items 13 to 15), (c) Personal Development (Items 10 to 12), (d) Emotional Well-Being (Items 1 to 3); (e) Rights (Items 23 and 24); (f ) Material Well-Being (Items 8 to 10), (g) Interpersonal Relationship (Items 4 and 5), and (h) Item 6 of Interpersonal Relationship. Loadings for each of the items in the factors were higher than .54 in every case. In order to conrm the proposed factor structure, we conducted repeated factor analyses across the larger subsamples (2 respondent, 3 geographical groups). If similar factor structures emerged, there would be a strong argument for the crosscultural universality of the eight core QOL domains. First, analyses by groups were performed, with professionals being the rst respondent group analyzed. Principal components analysis with Varimax rotation showed a seven-factors solution that together account for the 71.2% of the variance, with eigenvalues from 11.3 to .72. The factors reproduced the proposed model, with the exception of items of Self-Determination and Social Inclusion (Items 17 to 22), which grouped together into a single factor. Loadings ranged from .44 to .83. The second analysis involved the ratings from the users. Initial eigenvalues ranged from 8.66 (Factor 1) to .74 (Factor 8), with a cumulative percentage of 64.8. The rotated component matrix replicated the eight-factor solution from the total sample. Items loadings ranged from .50 to .80. Given that these two groups had the highest number of participants, it provides enough evidence supporting the multidimensional model across respondent groups. Similar analyses were conducted on three geographical groups. In reference to the Spanish par303

Analysis of Variance
Mean scores and SDs across the importance ratings for the eight core domains were calculated. A two-way factorial analysis of variance on these data (see Table 4) indicated (a) signicant main effects on importance ratings; (b) signicant effects due to the respondent group, with the exception of Social Inclusion; (c) signicant effects among geographical groups; and (d) a signicant interaction between the two factors on each of the eight QOL domains. Regarding geographical groups, post hoc tests (Duncan and Scheffe ) showed that Mainland China scores were signicantly lower, p .01, than the other geographical groupings. Concerning participant groups, post hoc tests (Duncan and Scheffe ) showed that professionals scores were signicantly lower, p .01, than the other two respondent groups in seven out of the eight domains and that families scored signicantly higher, p .01, than did the other two respondent groups in Social Inclusion.

Table 3. Cross-Tabulation Geographic Group by Importance (%)

Importance Geographic group 1.00 Spain Latin-America USA Canada China Average 1.5 0.9 1.2 0.8 3.7 1.6 2.00 5.0 5.3 6.2 8.1 14.8 7.9 3.00 18.5 20.9 23.1 28.4 41.1 26.4 4.00 75 73 69.5 62.8 40.4 64.1

Note. 1 not important at all to 4 very important.

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Table 4. Two-Way Factorial ANOVA (Importance)

Domain/Variance source Emotional Well-Being Main effects Group Geographic group Group Geographic Interpersonal Relations Main effects Group Geographic group Group Geographic Material Well-Being Main effects Group Geographic group Group Geographic Personal Development Main effects Group Geographic group Group Geographic Physical Well-Being Main effects Group Geographic group Group Geographic Self-Determination Main effects Group Geographic group Group Geographic Social Inclusion Main effects Group Geographic group Group Geographic Rights Main effects Group Geographic group Group Geographic
* p .01.

Sum of squares 89.34 4.41 80.71 9.47 59.30 3.02 52.35 8.32 63.97 11.50 47.98 14.68 87.41 22.16 60.81 26.27 46.13 5.11 37.75 18.30 89.25 11.56 74.53 17.82 62.98 .62 59.72 16.48 60.21 6.30 49.97 23.88

df 6 2 4 8 6 2 4 8 6 2 4 8 6 2 4 8 6 2 4 8 6 2 4 8 6 2 4 8 6 2 4 8

Mean square 14.89 2.21 20.18 1.18 9.88 1.51 13.09 1.04 10.66 5.75 11.99 1.83 14.57 11.08 15.20 3.28 7.69 2.56 9.44 2.29 14.88 5.78 18.63 2.23 10.50 .31 14.93 2.06 10.04 3.15 12.49 2.99

F 75.98* 11.26* 102.96* 6.04* 46.03* 7.03* 60.96* 4.84* 36.21* 19.53* 40.74* 6.23* 48.94* 37.22* 51.07* 11.03* 36.58* 12.16* 44.90* 10.89* 42.51* 16.52* 53.24* 6.37* 30.09* .89 42.80* 5.91* 30.91* 9.70* 38.48* 9.19*

Group

Group

Group

Group

Group

Group

Group

Group

ticipants, the factor solution resulted in eight factors that together explained 65.87% of total variance. Initial eigenvalues ranged from 8.34 (Factor 1) to .83 (Factor 8). The rotated component ma304

trix resulted in eight factors whose items grouped according to the proposed model, with item loadings from .21 to .85. In reference to Latin-American participants, a seven-factor solution resulted American Association on Mental Retardation

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from the analysis, with eigenvalues ranging from 8.79 (Factor 1) to .81 (Factor 7), and a total of 62.8% of total variance explained. Items loading ranged from .22 to .79, and the items were grouped according to the proposed model, with the exception of two factors that loaded together: the Emotional Well-Being and Social Inclusion factors. Finally, given the lack of a sample large enough, we collapsed Canadian and American (i.e. North American) participants into a single group, and routine factor analysis (with PCA as extraction method and Varimax rotation) was used once again. In this case, a six-factor solution seemed best. Total variance explained was 67.15%, with eigenvalues from 10.23 to .82. Items loadings ranged from .26 to .83. The six factors grouped the items into (a) Material Well-Being and Personal Development, (b) Physical Well-Being, (c) Social Inclusion and Rights, (d) Interpersonal Relationships, (e) Self-Determination, and (f) Emotional Well-Being.

Results: Use Ratings Response Prole Analysis

The average scores on use across geographical areas showed similar proles, with mean scores higher than 2.5 for each of the countries and groups (see Table 5). However, as shown in Table 6, the ratings across geographic groups based on the percentage of respondents indicating scores of 1 (never), 2, 3, or 4 (always) showed signicant association (collapsing across groups) in the evaluation of the receipt and/or use of the QOL indicators in current services and supports, 2(12) 649.86, p .01. This result suggests that living in different countries affects use differentially.

Analysis of Variance
A two-way factorial analysis of variance was calculated for the four geographical groups and the three respondent groups. Results, as shown in Table 7, indicated (a) signicant main effects for all the domains, (b) signicant differences in par-

Table 5. Means on Use by Participant and Geographic Groups

Group/Geographical area Professionals Spain Latin-America USA Canada China Total Users Spain Latin-America USA Canada China Total Families Spain Latin-America USA Canada China Total 1 3.31 3.34 3.54 3.23 3.29 3.32 3.46 3.34 3.65 3.64 3.00 3.37 3.36 3.55 3.48 2.85 3.26 3.45 2 3.21 3.22 3.41 3.12 3.30 3.24 3.46 3.35 3.39 3.38 3.02 3.34 3.52 3.49 3.56 2.86 3.36 3.45 3 2.84 2.66 3.48 2.99 3.09 2.88 3.09 3.03 3.28 3.16 2.51 3.00 3.14 3.13 3.22 2.51 3.32 3.13 4 3.13 3.17 3.26 2.86 3.19 3.15 3.50 3.46 3.19 3.27 3.12 3.40 3.24 3.36 2.92 2.62 3.24 3.27 5 3.29 3.12 3.69 3.46 3.34 3.27 3.30 3.35 3.50 3.34 3.06 3.30 3.31 3.48 3.48 2.95 3.53 3.44 6 2.88 2.89 3.47 2.97 3.09 2.98 2.97 3.06 3.30 3.07 2.85 3.02 3.05 3.29 3.22 2.66 3.26 3.22 7 2.98 2.91 3.33 3.15 3.27 3.06 3.01 3.08 3.20 3.02 2.91 3.04 3.11 3.22 3.20 2.65 3.36 3.19 8 3.28 3.03 3.53 3.28 3.39 3.23 3.42 3.34 3.55 3.41 3.02 3.34 3.27 3.42 3.34 2.81 3.38 3.36

Note. 1 Emotional Well-Being, 2 Interpersonal Relations, 3 Material Well-Being, 4 Personal Development, 5 Physical Well-Being, 6 Self-Determination, 7 Social Inclusion, 8 Rights. A score of 1 never and 4 always.

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Table 6. Cross-Tabulation Geographic Group by Use (in %)

Use Geographic group 1.00 Spain Latin-America USA Canada China Average 5.4 4.2 3.5 3.6 3.1 4.0 2.00 16.3 17.4 12 19 16 16.1 3.00 29.7 30.8 28.6 39 41.9 34 4.00 48.6 47.6 55.9 38.5 38.9 45.9

ticipant groups in two domains (Emotional WellBeing and Personal Development), (c) signicant differences in geographic grouping, and (d) a signicant respondent by geographical groups interaction. Post hoc comparisons (Duncan and Scheffe ) showed that scores in the United States were signicantly higher, p .01, than the other three geographic groups in three domains: Material Well-Being, Physical Well-Being, and SelfDetermination. On the other hand, scores in Canada were signicantly lower, p .01, than in the other three countries in Self-Determination. Post hoc comparisons (Duncan and Scheffe ) among respondent groups showed that families scored signicantly higher, p .01, than the other two groups in six out of eight dimensions; users scored signicantly higher, p .01, than the other two groups in Personal Development; and professionals scored signicantly lower, p .01, than the other two groups in Rights.

importance dimension. Each factor solution ranged from seven to eight factors. Specically, for professionals, seven factors (Social Inclusion and Rights were combined) accounted for 70% of the variance (eigenvalues, 10.3 to .70; item loadings, .38 to .83); for users, the eight proposed factors accounted for 66.6% of the variance (eigenvalues, 9.10 to .79; item loadings, .30 to .84); for the Spanish sample, the eight proposed factors accounted for 65.2 % of the variance (eigenvalues, 8.35 to .80; item loadings, .19 to .83); for Latin Americans, seven factors (Social Inclusion and Rights were combined) accounted for 76.7% of the variance (eigenvalues, 10.14 to .74; item loadings, .33 to .80); and for the North American sample, the eight proposed factors accounted for 76.7% of the variance (eigenvalues, 11.43 to .72; item loadings, .27 to .81). Thus, the obtained data on both importance and use t well with the proposed eight-factor core QOL domain structure.

Discussion
Support was obtained in the present study for the three hypotheses. However, interpreting the etic and emic properties of the QOL construct depends on the type of data and the corresponding analysis. Specically, in the current study response proles based on mean importance and use scores were quite similar, supporting the etic or universal property of the assessed indicators. However, signicant respondent and group differences were obtained when analyzing the percentage of responses within each response category (not important to very important; never to always used). Thus, Hypothesis 1 was only partially supported. In reference to the analysis of mean scores (Hypothesis 2), signicant respondent and geographical group differences were obtained, reecting the constructs emic properties. In reference to the proposed factor structure (Hypothesis 3), the clusters and factors on importance and use generally grouped into the eight specied QOL domains, again suggesting the constructs etic or universal property. These ndings have three important implications for the cross-cultural study of the concept of QOL: understanding its etic and emic properties, the approach one uses in crosscultural QOL studies, and the purpose and use of cross-cultural data.

Factor Analysis
Just as with the importance ratings, we conducted an exploratory factor analysis on the 24 use scores, collapsing across respondent and geographical groups. A priori selection of eight factors to be extracted was established in order to explore the viability of the theoretical model. Communalities ranged from .56 (Item 16) to .82 (Item 24). Initial eigenvalues ranged from 9.74 (Factor 1) to .68 (Factor 8), with a cumulative percentage of 69.11. An eight-factor solution grouped the 24 variables according to the eight-factor model, with the exception of Item 6, which loaded higher in the Physical Well-Being factor instead of in the Interpersonal Relationships factor. Items loadings ranged from .37 to .78. Repeated factor analyses across the same subsamples were conducted as had been done for the 306

Etic and Emic Properties

It is apparent from these data that the QOL construct has both etic and emic properties. Two American Association on Mental Retardation

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Table 7. Two-Way Factorial ANOVA (Use)

Domain/Variance source Emotional Well-Being Main effects Group Geographic group Group Geographic Interpersonal Relations Main effects Group Geographic group Group Geographic Material Well-Being Main effects Group Geographic group Group Geographic Personal Development Main effects Group Geographic group Group Geographic Physical Well-Being Main effects Group Geographic group Group Geographic Self-Determination Main effects Group Geographic group Group Geographic Social Inclusion Main effects Group Geographic group Group Geographic Rights Main effects Group Geographic group Group Geographic
* p .01.

Sum of squares 18.68 2.60 16.23 26.99 15.84 1.62 12.36 19.77 15.70 .24 15.56 65.64 31.23 11.26 22.34 17.96 6.88 .87 6.09 26.27 14.57 .29 13.59 19.84 10.95 1.58 8.98 23.59 8.64 1.50 7.12 37.87

df 6 2 4 8 6 2 4 8 6 2 4 8 6 2 4 8 6 2 4 8 6 2 4 8 6 2 4 8 6 2 4 8

Mean square 3.11 1.30 4.06 3.37 2.64 .81 3.09 2.47 2.62 .12 3.89 8.20 5.21 5.63 5.58 2.25 1.15 .44 1.52 3.28 2.43 .14 3.40 2.48 1.83 .79 2.25 2.95 1.44 .75 1.78 4.73

F 8.731* 3.641* 11.376* 9.462* 7.149* 2.201 8.369* 6.693* 4.919* .222 7.314* 15.420* 12.396* 13.410* 13.298* 5.348* 2.828* 1.075 3.756* 8.103* 4.291* .253 6.005* 4.384* 3.017* 1.303 3.710* 4.873* 2.435* 1.269 3.008* 8.003*

Group

Group

Group

Group

Group

Group

Group

Group

results from the current study support its etic property: (a) the similar response proles across the respondent and geographical groups in regard to the importance and use of the construct and American Association on Mental Retardation

(b) the generally conrmed eight-factor structure of the core QOL domains. However, in reference to the constructs emic properties, two results also suggest that one must be sensitive to the cultural 307

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properties of the QOL construct: (a) the signicant differences across respondent and geographical groups in the importance and use response categories and (b) the signicant difference in mean scores for importance and use across respondent and geographical groups. Collectively, these four results suggest strongly that how one answers the question regarding the etic and emic properties of the QOL construct depends heavily on the type of data collected and the subsequent analyses performed.

Cross-Cultural Studies
As just suggested, the construct of QOL has both universal and relativistic properties. Therefore, measurement in a cross-cultural context will require the use of instruments that are both robust (in that they can detect group differences) and stable (in that they are reliable and demonstrate stable factor structure). The robustness of the current survey instrument is demonstrated in its ability to detect signicant group differences, with consistently small standard errors of the means. Readers are cautioned, however, that there is more variance in the current USA and Canada geographical groups and the family respondent group. In cross-cultural research, stability is a multifaceted concept. At one level, it refers to the consistency (or reliability) of the instrument. In that regard, the reliability coefcients reported earlier are promising, but not denitive. In the current study, geographical and data-gathering constraints prevented establishing either testretest or interrater reliability coefcients. However, the second and third authors of this paper did demonstrate both types in two pilot studies that preceded the current data collection (Verdugo & Jenaro, 2004, unpublished study; Department of Psychology, University of Salamanca) Stability also refers to demonstrating similar factor structure and factor stability for the construct (in this case QOL) being evaluated (Everett & Entrekin, 1980; Kober & Eggleton, 2002). Factor structure can be demonstrated on one group of respondents, but factor stability requires that the same factor procedures applied to different sets of respondents produce factors that are stable between different sets of respondents (Everett, 1983). Although it is important to realize that only exploratory factor analysis was used in the present study, the results generally support the proposed eight-domain factor structure (depicted in Table 1) and cross-group stability. These results 308

suggest that in future studies (which are now underway by the authors), investigators conrm the constructs factor structure and stability and reconsider how the concept of supports should be conceptualized. With the current popularity of the supports paradigm, the importance and use of supports may be so pervasive as to either represent a separate QOL domain or be germane to each of the eight domains rather than an indicator (as shown in Table 1) for Interpersonal Relationships (wherein supports relate to emotional, physical, nancial feedback) and Social Inclusion (wherein supports relate to support networks and services).

Use of Cross-Cultural Data

Just as QOL is a multidimensional construct, it also has multiple uses. In reference to this study, the data can be employed for a number of purposes at the micro (individual) and macro (geographic group/cultural) levels. For example, at the micro level, rankings among the three respondent groups for the eight domains on importance and use can be determined based on the mean scores reported in Tables 2 and 5. Two trends are apparent in these data: (a) importance is rated higher than use and (b) there are apparent group differences. These differences may well account for attitudinal and conicting priorities across the three groups. For example, users and families ranked the importance of Emotional Well-Being, Personal Development, and Self-Determination higher than professionals did. Similarly, the different mean scores regarding use undoubtedly reect cultural variability and unique experiences with the services and supports provided. Schwartz and Rabinovitz (2003) have recently reported analogous differences regarding life satisfaction across service components. Thus, multiple perspectives need to be incorporated in cross-cultural QOL studies, and specic scores need to be viewed within the context of the respondent group. At the macro level, data in Tables 2 and 5 also clearly show that there are differences in both importance and use among the geographical groups. The broader (and potentially more important) question, however, is, What is the purpose of such comparisons? Increasingly, the QOL construct is being viewed as a tool for change, not a tool for comparison or judgment (Schalock & Verdugo, 2002). Thus, the research design one uses (whether it be a between-groups or a within-groups multivariate design) in crosscultural studies is dependent on the questions American Association on Mental Retardation

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asked. Subsequent investigators may well want to focus on answering the following four key research questions through the use of a combination of research designs. First, why does the QOL concept, as measured by the domains and indicators summarized in Table 1, play out better in some geographical areas than in others? Is it an issue of haves versus have nots, of collectivism versus independence; or is it due to a different emphasis on autonomy and individual liberty versus liberty, fraternity, or equality? Second, what are the cultural adaptations of the QOL construct? The rankings on the dimensions of importance and use discussed above are one way to approach answering this question, but there are potentially other dimensions, such as feasibility, desirability, or effectiveness. Third, which cultural factors facilitate the application of the QOL concept, and which factors inhibit or preclude its cultural acceptance and application? Fourth, what are the individual and societal predictors of a life of quality? Answering these questions will also require the use of adapted instruments (Herdman et al., 1997), but ones that focus on the emerging consensus and validation of the eight core QOL domains and their respective indicators as used in this and other studies (e.g., Schalock & Bonham, 2003). There is general agreement on the urgent need for research into the best ways of measuring and assessing the concept of QOL, giving particular attention to both subjective viewpoints and objective life events and circumstances (Anderson & Burckhardt, 1999; Cummins, 1996; Goodley, Armstrong, Sutherland, & Laurie, 2003; Perry & Felce, 2000; Saxena et al., 2001; Schalock & Felce, 2004; Schalock & Verdugo, 2002). Although the current study was focused on the subjective viewpoints of respondents regarding the importance and use of the QOL concept, future cross-cultural studies should also be focused on individuals objective life events and circumstances. In that regard, Schalock and Felce (2004) suggested the following two guidelines. First, to determine whether people with disabilities are as satised with life as are other population subgroups, subjective wellbeing should be assessed and compared. If the scores are different, one needs to look for personal or environmental factors that might explain such a difference. However, the expectation that subjective well-being will be a sensitive indicator of good environmental design and service programs has yet to be determined. Thus, the second guide American Association on Mental Retardation

line: To evaluate environmental design or service programs in a sensitive way, an investigator should use objective indicators of life experiences and circumstances. This second guideline is a clear recommendation to divorce subjective from objective appraisal and determine those variables that predict QOL-referenced outcomes. It is also important to realize that cross-cultural differences in QOL ratings or scores may reect cross-cultural differences in the legal and statutory position of people, variations in the availability and accessibility of services, differences in societal attitudes, contrasting outlooks and expectations, or an artifact of the research methods employed (Buck, Jacoby, Baker, Ley, & Steen, 1999). Although considered exploratory, the present study is not without limitations. First, the sample size for some geographical groups is small. We addressed this weakness by adding samples from Europe, North America, and the Pacic Rim. Second is the issue of cultural equivalence and/or cultural bias. As pointed out by two reviewers of the study, the problem of any study of QOL (which is a subjective construct) is that investigations of the construct are mediated by the specic measures used. Thus, the cross-cultural variation obtained may be the result of the lack of cultural equivalence and/or cultural bias in the measures used or a lack of reliability or validity in the measures used. Third, the sampling strategy employed in the present study places limits on the conclusions and generalizations in regard to national variation on importance and use. There is a need in subsequent studies for researchers to incorporate a follow-up strategy that would allow more qualitative explanations of the importance and use response dimensions. Fourth, the current sample precluded comparison of subsamples related to different living and employment environments due in large part to how these services are dened in different countries. We were unable to analyze potential differences in (and the contributions of ) user characteristics for the same reason. Fifth, the factor structure of the core QOL domains needs to be conrmed on a larger sample through conrmatory factor analysis. Finally, the etic and emic properties of the QOL construct need to be validated on a larger sample and through a more robust statistical procedure, such as structural equation modeling, that is a part of the expanded and ongoing study. In conclusion, through cross-cultural studies such as this one, investigators can begin to answer 309

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a number of fundamental questions regarding the QOL concept and its use in program services and supports to persons with intellectual disabilities. Over the last 2 decades, the concept of QOL has been used as a sensitizing notion, a social construct, and a unifying framework for its conceptualization, measurement, and application. In addition, in many countries, the concept has also become a social movement whose purposes are similar to earlier efforts related to civil rights, deinstitutionalization, normalization, mainstreaming, and inclusion. If QOL is to continue to be a viable social construct and unifying framework to guide international efforts, future cross-cultural studies need to be designed to address at least three key questions: How can the concept of QOL be integrated into the major social forces impacting human behavior? What is the proper use of QOL data? Does the measurement and application of QOL principles and techniques make a difference in peoples lives? Hopefully, in the present study we have begun to address those key issues in a meaningful way.

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drawn from the WHOQOL development. Quality of Life Research, 11, 135144. SPSS, Inc. (1998). SPSS base 8.0 for windows users guide. Chicago: Author. Tapsoba, H., Deschamps, J. P., & Leclercq, M. H. (2000). Factor analytic study of two questionnaires measuring oral health-related quality of life among children and adults in New Zealand, Germany, and Poland. Quality of Life Research, 9, 559569. Tasse , M. J., & Craig, E. M. (1999). Critical issues in the cross-cultural assessment of adaptive behavior. In R. L. Schalock (Ed.), Adaptive behavior and its measurement: Implications for the eld of mental retardation (pp. 161184). Washington, DC: American Association on Mental Retardation. Verdugo, M. A., Prieto, G., Caballo, C., & Pela ez, A. (in press). Factorial structure of the Quality of Life Questionnaire in a Spanish sample of visually disabled adults. European Journal of Psychological Assessment. Received 3/11/04, accepted 8/25/04. Editor-in-charge: David Felce The sixth author is also afliated with Key Laboratory of Special Education-Chong Qing Normal University. The research in Spain and Latin America was supported by the Ministry of Science and Technology of Spain (BS 0200303059) and the European Fund of Regional Development (FEDER). Requests for reprints should be sent to Robert L. Schalock, PO Box 285, Chewelah, WA 99109. E-mail: rschalock@ultraplix.com

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