Validation of the World Health Organization Quality of Life HIV Instrument in a Zambian Sample

Article Outline

• Abstract
• HIV in Zambia
• WHOQOL Development
• WHOQOL-HIV
• Methods
  • Instrument
  • Analysis
• Results
  • Sample Characteristics
  • QOL Factor Structure Analysis
    • Physical domain
    • Psychological domain
    • Level of independence domain
    • Social relationships domain
    • Environment domain
    • Spirituality religion personal beliefs domain
    • QOL second-order factor analysis
• Discussion and Conclusions
• Conclusion and Implications
• Disclosures
• References
• Biography
• Copyright

Given the longevity achievable with the current treatment for people living with HIV, quality of life (QOL) has emerged as a significant health outcome measure. The purpose of this study was to test the QOL factor structure in a Zambian sample using the World Health Organization Quality of Life-HIV (WHOQOL-HIV) instrument. A cross-sectional 2 × 2 factorial design was conducted with 160 people living with HIV. Factor analysis yielded 3 new scales: Zambian WHOQOL-HIV, Zambian WHOHIV Medication Dependence, and Zambian WHOHIV spirituality religion personal beliefs (SRPB), and validated the Overall Quality of Life and General Health Perceptions Scale. The study tested the WHOQOL-HIV instrument, validated a scale that can be used for regular assessment, and yielded three comprehensive QOL assessment scales to monitor disease progression and response to care. The assessments will lead to the development of holistic nursing interventions based on perception of QOL.

Key words: AIDS, factor analysis, HIV, quality of life, QOL Scales, Zambia

Given the longevity achievable with the current prophylactic and therapeutic strategies for people living with HIV (PLWH), quality of life (QOL) has emerged as a significant measure of health outcome, and enhancement of QOL has emerged as an important goal (Bachmann, 2006, Douaihy and Singh, 2001). QOL research has led to the recognition of its importance and the need to incorporate quality concerns into health care practice (Grossman, Sullivan, & Wu, 2003). Although common themes cut across the studies on QOL, most research has been conducted in developed countries, making generalizations to developing countries difficult. Little is known about QOL in impoverished developing countries such as Zambia (Saxena et al., 2002, Skevington and O'Connell, 2003). The concept of QOL can be traced back to 1947 and to the World Health Organization (WHO; Grossman et al., 2003), which defined QOL as “individuals' perception of their position in life in the context of the culture and value system in which they live and in relation to their goals, expectations, standards and concerns” (WHO Quality of Life [WHOQOL] Group, 1995, p. 1405). Although this definition has not yet been fully embraced by QOL researchers, it captures most generally agreed upon areas.

Furthermore, WHO has developed both generic and disease-specific instruments to assess QOL. These instruments have been used for a variety of purposes including practice, research, and evaluation of services. The purpose of this study was to test the quality-of-life factor structure of a Zambian sample using the Health Organization Quality of Life-HIV (WHOQOL-HIV) instrument.

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HIV in Zambia 

By 2003, Zambia, a country in sub-Saharan Africa, had a population of 11,291,795, with an HIV prevalence of 16.9% (Central Statistics Office/Central Board of Health, 2002, Dzekedzeke and Fylkesnes, 2006). By 2004, HIV prevalence rates were estimated to be significantly higher for women (17.8%) than for men (13%) in Zambia (CSO/CBoH, 2002). The 2006 HIV infection rate demonstrated that women accounted for more than half (57%) of the adults infected by the virus (Joint United Nations Programme on AIDS [UNAIDS]/WHO, 2006). HIV prevalence in Zambia exceeds the prevalence rate for both sub-Saharan Africa (7.5%) and global (1.1%) rates (UNAIDS/WHO, 2006). The majority of Zambian PLWH seeks health care in late stages when they have already qualified for a diagnosis of AIDS (National AIDS Council, 2003). Such practices have led to high morbidity and mortality rates for PLWH in Zambia. By 2006, an estimated 98,000 Zambian PLWH had died of the infection. Life expectancy at birth fell from 60 to 40 years largely because of HIV (UNAIDS/WHO, 2006).

It is anticipated that, with the provision of antiretroviral therapy, Zambian PLWH will have better QOL and begin to live longer, seek health care earlier, and accept HIV as a chronic illness. Therefore, there is need to identify tools that can be used to monitor QOL of PLWH so as to provide early assistance.

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WHOQOL Development 

The WHOQOL model was designed to be culturally sensitive and to tap the views of the populations studied. Development involved a series of steps by an international collaboration of 15 field centers across countries. The centers carried out the work simultaneously, and at each stage a common protocol was agreed upon across the centers (World Health Organization Quality of Life Group, 1995, World Health Organization Quality of Life Group, 1996). Patients, healthy people, and health professionals all had input on what constituted the important aspects of QOL.

The initial step had phases that included clarification of the QOL concept, development of a definition of QOL, and an agreement to an international QOL measurement by a panel of international experts. The second major step was the collection of qualitative data through focus group discussions within each center for further cross-cultural exploration of QOL. On completion of the focus group work, a writing panel framed QOL questions in comprehensible and natural language, resulting in 234 items for the WHOQOL pilot instrument. A five-point Semantic Differential Response Scale (1-5, with 5 being high) was used for each item (WHO, 2002).

The questions were further subdivided into facets, a concept that is measured by a set number of items. A maximum of six questions comprised a facet and 29 facets were identified. This process led to the subsequent identification and definition of the domains of QOL. Domains are dimensions of QOL that are composed of a set of facets. The identified domains of QOL are physical, psychological, level of independence, social relationships, environment, and spirituality religion personal beliefs (SRPB; WHOQOL Group, 1998).

The WHOQOL instrument was pilot tested to examine the construct validity of the facets and domains, select the best questions, and establish reliability and discriminant validity. It was administered to 250 patients with chronic illnesses and 50 healthy people in the 15 field centers. A series of smaller studies were conducted in different centers with homogenous samples to further validate and establish the instrument”s sensitivity to change, test-retest reliability, and criterion validity, specifically with regard to convergent, discriminant, and predictive validity (Saxena et al., 2005, Skevington et al., 1999). Testing resulted in a final questionnaire containing 100 items and, thus, was named the WHOQOL-100.

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WHOQOL-HIV 

Although the WHOQOL-100 has been used in different settings with persons suffering from a variety of diseases, in 1999, it became apparent that there was need to develop disease-specific QOL instruments, such as for HIV-infected patients (Skevington and O'Connell, 2004, World Health Organization Quality of Life-HIV Group, 2003a). The WHOQOL-HIV instrument development process began in 2000 to ascertain assessment of relevant aspects of QOL as experienced by PLWH. The WHOQOL-HIV instrument was intended to help in better planning, delivery, and evaluation of PLWH in diverse cultures; provide for appraisal of outcome of antiretroviral medication; and support policy decisions regarding resource allocation (Skevington et al., 1999, World Health Organization Quality of Life-HIV Group, 2003b).

The six original domains of WHOQOL anchored the HIV model and served as a guide in the development of the WHOQOL-HIV instrument. The WHOQOL-100 was reviewed by a group of 18 international experts, from both developed and developing countries. This review led to additional questions and facets so as to extend the suitability and sensitivity for the HIV population (Skevington et al., 1999, World Health Organization Quality of Life-HIV Group, 2003b). The developed instrument was pilot tested in six culturally diverse sites in Australia, Brazil, India, Thailand, Zambia, and Zimbabwe (O'Connell et al., 2004, Skevington et al., 1999, World Health Organization Quality of Life-HIV Group, 2003a). This process yielded an additional 115 HIV-related items that were reduced to 16 items through standard psychometric procedures. The 16 HIV-specific questions were incorporated into the generic 100 items of the WHOQOL to make up 116 items on the WHOQOL-HIV instrument.

The WHOQOL-HIV was then pilot tested on a sample of 900 participants from five of the six pilot centers, but not Zambia (WHOQOL-HIV Group, 2003a). The results showed very good internal consistency for the overall QOL (α = .98) and for the six domains of QOL (α = .87-.94). Additionally, the integrated items showed good intercorrelations (above .4; WHOQOL-HIV Group, 2003a).

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Methods 

A cross-sectional, correlational, four-group (rural/urban/men/women) 2 × 2 factorial design using a convenience sample of 160 PLWH was conducted. The study was conducted in two urban and two rural sites in Zambia and had equal proportions of participants from each, as well as equal proportions of male and female participants. The study was approved by the Kent State University Institutional Review Board and the University of Zambia Research and Ethics Committee. Clinic managers recruited subjects from antiretroviral clinics. Of 166 persons approached to participate, 160 (96.38%) completed surveys. Bus fare of K10,000 (US $10) was offered to all participants.

A power analysis was conducted using the SamplePower SPSS version 14.0 program (SPSS Inc., an IBM Company, Chicago, IL) for detecting a nonzero sample correlation at a significance level (alpha) of .05 on a two-tailed test and a medium effect size (.25). Power analysis yielded a sample of 160 for a power of .88. The sample size allowed for participants to be stratified into four equal groups (80 participants per group on the basis of gender and rural or urban residence).

Instrument 

The WHOQOL-HIV instrument has 116 QOL items divided into 29 facets and is in the public domain. The 116 items maintained the names of the original six domains of the WHOQOL: physical, psychological, level of independence, social relationships, environment, and SRPB.

The physical domain is composed of four facets (16 items) that measure pain and discomfort, energy and fatigue, sleep and rest, and symptoms of HIV infection. The psychological domain is composed of five facets (20 items) that measure positive feelings; thinking, learning, memory, and concentration; self-esteem; body image and appearance; and negative feelings. The level of independence is composed of four facets (16 items) that measure mobility, activities of daily living (ADL), dependence on medication or treatments, and work capacity. The social relationships domain is composed of four facets (16 items) that measure personal relationships, social support, sexual activity, and social inclusion. The environment domain has eight facets (32 items) that measure physical safety and security; home environment; financial resources; health and social care, accessibility and quality; opportunities for acquiring new information and skills; participation in and opportunities for recreation/leisure activities; physical environment (pollution, noise, traffic, climate); and transport. The SRPB domain has four facets (16 items) that measure spirituality, forgiveness and blame, concerns about the future, and death and dying (Starace et al., 2002, World Health Organization Quality of Life SRPB Group, 2006, Zimpel and Fleck, 2007).

A total of 116 items were collected from the WHOQOL-HIV instrument. Forty-eight items were negatively phrased. All negatively framed items were reverse scored as directed in the WHOQOL-HIV instrument users' manual (WHO, 2002).

Analysis 

Data were analyzed using the Statistical Package for Social Scientists (SPSS) version 14.0. Data were checked and verified before factor analysis of the principal components. All responses were scored as stipulated by the WHOQOL-HIV Manual (WHO, 2002). Domain scores were calculated by computing the mean of the facet scores for each domain. Mean scores were then multiplied by four so that the domain scores ranged from 4 (lowest possible QOL) to 20 (highest possible QOL). Domain scores were summed and divided by number of domains to obtain the QOL score. The WHOQOL-HIV produced a QOL profile.

A principal components factor analysis using Varimax rotation with Kaiser Normalization was used to examine the dimensions as theoretically specified for QOL. Factor analysis was conducted for each of the six domains (physical, psychological, level of independence, social relationships, environment, and SRPB) of the WHOQOL-HIV. The resultant domains were subjected to a second order analysis to determine a single structure of QOL.

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Results 

Sample Characteristics 

The majority of the participants were between the ages of 18 and 45 years (84.4%; M = 36.52, SD = 8.98). Forty-seven percent of the participants were either married or living with a partner. Almost half of the participants (46.9%) were high school graduates. Approximately 43% of the respondents were not employed. About one third of the participants (30%) earned less than K150,000 (US $42.86) per month. All sample characteristics were similar to those of the general population of PLWH in Zambia (CSO/CBoH, 2003).

More than half of the study sample (53.8%) perceived their health as good. More than two thirds of the participants (68.1%) did not consider themselves currently ill. Almost half of the participants (45%) said they were asymptomatic, whereas 25% said that they had progressed to AIDS, and 44% had been treated for tuberculosis. The majority of the participants (86.9%) were taking antiretroviral medication. More than 32% of the respondents had only been on antiretroviral therapy for 12 months or less. Of the 114 participants who provided a CD4+ T-cell count, one third (28%, n = 32) had a CD4+ T-cell count of 200 cells/mm³ or lower; and the mean CD4+ T-cell count was 358.35 cells/mm³.

QOL Factor Structure Analysis 

The factor analysis procedure followed for each domain included examining the means for each of the items in a domain, variance explained, initial scree plot to determine the number of factors by examining the disjuncture on the plot, and component matrix to see the loading of factors. Factors with loading of .4 or greater were retained (Carmines & Zeller, 1974). In cases in which the decision of the number of factors to retain needed further examination, the eigenvalue was used, and in those cases factors with eigenvalues greater than 1 were retained (Mertler and Vannatta, 2005, Tabachnick and Fidell, 2001).

The next step involved creation of scales for the resultant factor(s) by summing all items and dividing by the total number of items in a particular scale. Reliability of the created scales was determined using Cronbach's alpha coefficients. Reliabilities of .80 and greater were accepted as strong and suitable for use in further analysis (Carmines & Zeller, 1974). Finally, a histogram was produced with the normal curve to outline the normality of the scale to determine whether there was need for nonlinear transformation (Mertler and Vannatta, 2005, Tabachnick and Fidell, 2001). Nonlinear transformations are conducted when skewness is greater than .2 (Carmines & Zeller, 1974). Deviations from the aforementioned procedure will be explained for domains that did not factor cleanly.

Means of the 16 items ranged from a low of .86 to a high of 4.24, with standard deviations ranging from .86 to 1.18. Examination of the variances revealed that the factor structure accounted for 39.78% of the variance in the matrix. The scree plot showed a single factor for the physical domain. The component matrix in Table 1 shows all 16 items loaded on a single factor, the physical domain. These factor loadings ranged from a low of .440 for item f50.3 (prevent you from doing what is important) to a high of .738 for item f3.4 (satisfaction with sleep). Using a minimum of .4 loading, physical domain was defined by all 16 items with a Cronbach's alpha of .895.

Table 1. Physical Domain Scale 16-Item Principal Component Matrix (N = 160)

NOTE: Extraction method: Principal component analysis, Rotation method: Varimax with Kaiser normalization, rotation converged in six iterations.

Means of the 20 items ranged from a low of 2.79 to a high of 4.38, with standard deviations ranging from .91 to 2.79. The variances revealed that a two-factor structure accounted for 44.76% of the variance in the matrix, in which the first component accounted for 32.94% and the second for 11.82%. The scree plot showed that a disjuncture occurred between factors 2 and 3 (strong on factor 1 and weak on factor 2). The strong factor was positive and the weak was negative. This finding can be interpreted as having one or two factors because factor 2 was weak, and there were positive and negative factors. Therefore, both one-factor and two-factor structures were explored.

As an initial step, a two-factor structure was considered. The first factor was defined by 14 items indicating a positive, satisfied, confident self. This factor was named “Positive.” The second factor was defined by six items indicating a negative, inhibited, uncomfortable, worried, sad self. This factor was named “Negative.” Correlations between scales made up of Positive and Negative View of Self items with the other domain scales of the WHOQOL-HIV were then calculated. Of the nine pairs of correlations, only one was statistically significant. The Activity Scale was more strongly correlated with the Positive View of Self Scale (r = .792, p = .01) than with the Negative View of Self Scale (r = .530; p = .01). Similarities between the two factors could be interpreted as the items were measuring one factor (Carmines & Zeller, 1974). Therefore, a decision to turn to the single-factor structure for further analyses was made.

Factor loadings of the 20 items of the psychological domain on a single factor ranged from a low of .288 to a high of .772. Using a minimum of .4 loading, factor 1 was defined by 18 items because the other two items, item f4.4 (generally feel content) and item f7.4 (experience positive feelings) did not have sufficient loading. The two items both belonged to the positive feelings facet and were eliminated from further analyses. The component matrix in Table 2 shows the factor loadings of the 18 items ranging from a low of .423 to a high of .779 with a Cronbach's alpha of .889.

Table 2. Psychological Domain 18-Item Component Matrix (N = 160)

NOTE: Extraction method: Principal component analysis, Rotation method: Varimax with Kaiser normalization, rotation converged in three iterations.

Means of the 16 items ranged from a low of 2.67 to a high of 4.02, with standard deviations ranging from .93 to 2.22. The variances revealed that a two-factor structure accounted for 56.73% of the variance, in which the first component accounted for 39.13% of the variance and the second for 17.61%. The scree plot showed a disjuncture between the second and the third factors, suggesting two clear factors (activity and medication dependence) with eigenvalues greater than 1.

Using a minimum of .4 loading, Table 3 reveals that factor 1 was defined by 12 items, consistent with the work, mobility, and ADL facets. Factor loadings for the first factor ranged from a low of .527 to a high of .852 and were named and summed into an activity domain with a Cronbach's alpha of .889. The four items loaded on the second factor were consistent with a Dependence on Medication and Treatments Facet. Factor loadings for the second factor ranged from a low of .572 to a high of .874 and were named and summed into a medication dependence domain with a Cronbach's alpha of .834.

Table 3. Level of Independence Domain Rotated Component Matrix (N = 160)

NOTE: Extraction method: Principal component analysis, Rotation method: Varimax with Kaiser normalization, rotation converged in five iterations.

QOL = Quality of Life.

Means of the 16 items ranged from a low of 2.44 to a high of 4.08, with standard deviations ranging from .91 to 1.34. Variances revealed that the first factor accounted for 39.65% of the variance in the matrix. The scree plot showed a disjuncture between factors 1 and 2 suggesting a single factor. Factor loadings on a single factor ranged from a low of −.097 to a high of .845. Using a minimum of .4 loading to define a factor, three items had low loadings: .260 for item f15.4 bothered by difficulties in sex life, .144 for item f15.2 fulfillment of sexual needs and inclusion, and −.097 for item f51.4 feel alienated from those around you. These three items were eliminated. The factor loadings of the 13 items in Table 4 ranged from a low loading of .442 to a high of .849 and were named and summed into a social relationship domain with a Cronbach's alpha of .897.

Table 4. Social Relationship Domain 13-Item Component Matrix (N = 160)

NOTE: Extraction method: Principal component analysis, Rotation method: Varimax with Kaiser normalization, rotation converged in five iterations.

Means of the 32 items ranged from a low of 2.44 to a high of 3.63, with standard deviations ranging from .94 to 1.42. The variances revealed that one factor accounted for 33.27% of the variance in the matrix. The scree plot showed a disjuncture between factors 1 and 2 suggesting a single factor. The factor loadings ranged from a low of .308 to a high of .744. Using a minimum of a .4 factor loading, Table 5 shows two items with low loadings (.322 for item f19.2 rate quality of social services available to you and .308 for item f308 worry about safety and security) that were eliminated from further analyses. One of the items with low factor loadings was from the health and social care facet, whereas the other was from the physical safety and security facet. Factor loadings of the remaining 30 items ranged from a low of .429 to a high of .746 and were named and summed into an environment domain with a Cronbach's alpha of .933.

Table 5. Environment Domain 30-Item Component Matrix (N = 160)

NOTE: Extraction method: principal component analysis, Rotation method: Varimax with Kaiser normalization, rotation converged in three iterations.

Means of the 16 items ranged from a low of 2.99 to a high of 3.94, with standard deviations ranging from 1.09 to 1.39. Variances revealed that a three-factor structure accounted for 63% of the variance in the matrix, in which the first component accounted for 36.37% of the variance, the second for 16.50%, and the third for 10.12%. The scree plot showed a disjuncture between factors 3 and 4, suggesting a three-factor structure. The component matrix showed that four items (item f53.4 fear of the future, item f54.4 preoccupation about suffering before dying, item f53.1 concerned about HIV status breaking family line, and item f54.1 worry about death) loaded on both factors 1 and 2.

Two of the four items that loaded on both factors 1 and 2 were from the death and dying facet, whereas the other two were from concerns about the future facet. The similarities between factors 1 and 2 could be interpreted that the two factors were actually one factor. Hence, two factors were considered for further analyses.

Factor analysis was rerun specifying two factors. The factor loadings for two factors were examined. Table 6 reveals that factor 1 was defined by 12 items consistent with the forgiveness and blame, concerns about the future, and death and dying facets. These factor loadings ranged from .407 to .810 and were named and summed into a personal beliefs domain with a Cronbach's alpha of .892. Factor 2 was defined by four items consistent with the SRPB facet. These factor loadings ranged from a low of .563 to a high of .845 and were named and summed into an SRPB domain with a Cronbach's alpha of .829.

Table 6. Spirituality Religion Personal Beliefs Domain Two-Factor Component Matrix (N = 160)

NOTE: Extraction method: Principal component analysis, Rotation method: Varimax with Kaiser normalization, rotation converged in three iterations.

SRPB = spirituality religion personal beliefs.

After determining the factor structures of the domains of QOL, the next step was to create a single QOL structure. A second-order factor analysis was conducted using the eight domain scales developed from the aforementioned analysis. Table 7 shows that all eight domains had mild negative skewness that did not warrant nonlinear transformations. Furthermore, all eight scales had strong reliability above .80.

Table 7. Quality of Life Second Order Rotated Component Matrix (N = 160)

NOTE: Extraction method: Principal component analysis; Rotation method: Varimax with Kaiser normalization; Rotation converged in three iterations.

Factor analysis was conducted to determine what, if any, underlying structure exists for the eight domains consisting of physical, psychological, activity, medication dependence, social relationships, environment, personal beliefs, and spirituality domains. The eight domain means ranged from a low of 11.36 for the medication dependence domain to a high of 15.24 for the psychological domain, with standard deviations ranging from 2.44 for the psychological domain to 3.84 for the SRPB and medication dependence domains. Variances revealed that a two-factor structure accounted for 63% of the variance in the matrix, in which the first component accounted for 53.16% of the variance and the second for14.76%. The scree plot showed a disjuncture between the second and third factors, suggesting one strong factor and a second relatively weak factor. Both the first and second factors had eigenvalues of less than 1, and the third factor had an eigenvalue of .78, suggesting a two-factor structure. The descriptive statistics for these eight scales are in Table 8.

Table 8. Descriptive Statistics of Resultant Eight Domains (N = 160)

The first factor was identified by six items: physical, psychological, activity, social relationships, environment, and personal beliefs domains. The factor loadings on the first factor, which ranged from a low of .649 for the personal beliefs domain to a high of .906, was summed and named the Zambian WHOQOL-HIV scale with a Cronbach's alpha of .896.

Factor loadings on the second factor had one positive (factor loading, .699) and one negative (factor loading, −.801) factor. The positive factor was summed and named the Zambian WHOHIV SRPB Scale with a Cronbach's alpha of .829 and the negative was summed and named the Zambian WHOHIV Medication Dependence Scale with a Cronbach's alpha of .834.

Therefore, three scales, the Zambian WHOQOL-HIV Scale, the Zambian WHOHIV SRPB Scale, and the Zambian WHOHIV Medication Dependence Scale, were derived from factor analysis. The six domains that loaded on total QOL were considered the domains of QOL.

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Discussion and Conclusions 

Factor analysis was conducted using the WHOQOL-HIV model to test fit on a Zambian sample of PLWH. As noted earlier, a search of the published data found that only two studies, the initial pilot testing of WHOQOL-HIV (WHOQOL-HIV Group, 2003a) and one Brazilian study on HIV-infected participants (Zimpel & Fleck, 2007), reported factor analyses of the WHOQOL-HIV. Therefore, the factor analysis results of the current study will focus on the comparisons with these two studies.

Four of the six domains (physical, psychological, social relationships, and environment) yielded a one-factor structure as conceptualized by the WHOQOL-HIV Group (2003a), whereas the other two domains (level of independence and SRPB) yielded two-factor structures. However, seven items were eliminated from three domains (psychological, social relationships, and environment) because of low factor loadings. Physical domain was the only domain that yielded a one-factor structure and retained all 12 items as conceptualized by the WHOQOL-HIV model. This may mean that physical domain is much more comparable internationally than the other domains. The four domains that yielded one-factor structures (physical, psychological, social relationships, and environment) had good internal consistency, with Cronbach's alphas ranging from .889 to .933. These Cronbach's alphas were stronger than those of the preliminary WHOQOL-HIV Group (2003a) study (.45-.86) and the Brazilian (.32-.88) study (Zimpel & Fleck, 2007).

Two items were eliminated from the psychological domain because of low factor loadings that assessed positive feelings (f4.2 Do you generally feel content? and f4.4 How much do you experience positive feelings in your life). This suggests that the psychological domain may exhibit slight differences among different cultures. It was, however, not clear why these two items, both from the positive feelings facet, had low factor loadings, and further exploration of the items is necessary. The wording of facets may not have been clear because they were not typical word choices used in conversation.

Three items were eliminated from the social relationships domain because of low factor loadings, of which two were eliminated because of low factor loadings that assessed sexual relations (f15.2 How well are your sexual needs fulfilled? and f15.4 Are you bothered by any difficulties in your sex life?). It is important to note that the two items that measured sexual relations were those that had the highest nonresponse data and that this could be attributed to their low loading. Respondents who did not reply also stated that they were not currently sexually active. Nonresponse could have also occurred because some respondents chose not to respond to sex-related items because of cultural reasons such as not being able to discuss sex openly.

Furthermore, sexuality questions were part of the generic items on the WHOQOL-Instrument and may not have been applicable to HIV-infected patients who were not sexually active. The WHOQOL Group acknowledged that it is difficult to ask about sexual activity and that responses to these questions may be guarded. Some participants may report little or no desire for sex without this having any adverse effect on their QOL (World Health Organization Quality of Life Group, 1993, World Health Organization Quality of Life Group, 1998).

The third item eliminated from the social relationship domain assessed inclusion (f51.4 How much do you feel alienated from those around you?). This item may have had less variability because it may have been difficult to determine alienation in a culture that embraced extended family lifestyle and households having an average of six people (CSO & Ministry of Health, 2003). In households where people live closely together, it could be likely that participants received some type of social support. Although stigma and discrimination toward PLWH could lead to alienation, this finding may indicate that PLWH were beginning to be less stigmatized and discriminated against and hence did not feel alienated from those around them.

Two items were eliminated from the environment domain because of low factor loadings, the first one eliminated because of low factor loading assessed physical safety and security (f16.3 How much do you worry about your safety and security?). It is important to note that this item belonged to the environment domain facet that assessed physical safety and security. The physical safety and security facet had the lowest Cronbach's alpha during preliminary testing of the instrument (.45; WHOQOL-HIV Group, 2003a) and also on the Brazilian sample (.32; Zimpel & Fleck, 2007). Although there are reports of virgin cure and sexual abuse (Milimo, Munachonga, Mushota, Nyangu, & Ponga, 2004) that could lead to an expectation that people would be more worried about their physical safety and security, participants in our study did not report being worried. This may have been because physical safety and security was more related to strife and unrest than to sexual abuse. Zambia, unlike many Southern African countries, did not experience civil or political strife and unrest after independence from colonialism. However, the finding is in agreement with the fact that participants did not feel alienated from others. There is a tendency to feel safe when one has support. This implies that further exploration of the items is necessary.

The second item eliminated from the environment domain because of low factor loading belonged to the care facet (f19.2 How would you rate the quality of social services available to you?). It is speculated that it may have been difficult for the participants to rate the quality of social services when few social or recreation services were available. Cultural activities, such as baby naming ceremonies, occurred especially in the rural areas and provided recreation. It could be speculated that these activities may not have been considered recreational services.

The remaining two of the six domains (level of independence and SRPB) did not factor as conceptualized by the WHOQOL-HIV model. The level of independence and SRPB domains retained all the items but yielded two-factor structures. The level of independence domain has four facets. The next section will describe the two-factor structures of the level of independence and SRPB domains.

The level of independence domain had 16 items that measured four facets: mobility, ADL, working capacity, and dependence on medication or treatments. The first factor retained 12 items from three facets (mobility, ADL, and working capacity) with a Cronbach's alpha of .889 and was named the activity domain. The second factor, with a Cronbach's alpha of .834, retained all four items of one facet (dependence on medication or treatments) and was named medication dependence domain. Both scales had stronger internal consistency than the .79 to .94 of the initial pilot testing of the WHOQOL-HIV instrument study (WHOQOL-HIV Group, 2003a) and the .78 to .92 of the Brazilian study (Zimpel & Fleck, 2007).

The dependence on medications and treatments facet is conceptualized by the WHOQOL-HIV group to examine an individual's dependence on medication or alternative medicines, such as acupuncture, and herbal remedies for supporting physical and psychological well-being. The facet also included medical interventions that were not pharmacological, but on which the person was still dependent, such as pacemaker, artificial limb, colostomy bag, wheel chair, or oxygen (World Health Organization, 2002, World Health Organization Quality of Life Group, 1994). The four items of the conceptualized facet loaded on one factor, stood out as a domain in our study, which was named medication dependence domain. It was speculated that unavailability of other medical aids, especially for the rural participants, could be the reason medication dependence was different from that of the hypothesized model (Central Board of Health, 2004, Central Statistics Office/Central Board of Health, 2002). Nonetheless, there is a need to further explore the items because the initial pilot testing of the WHOQOL-HIV instrument study (WHOQOL-HIV Group, 2003a) and the Brazilian study (Zimpel & Fleck, 2007) also reported low means for this domain.

The second domain that yielded a two-factor structure was the SRPB domain, which had 16 items assessing four facets (SRPB, forgiveness and blame, concerns about the future, and death and dying). The SRPB domain's first factor retained 12 items from three facets (forgiveness and blame, concerns about the future, and death and dying) with a Cronbach's alpha of .892 and was named personal beliefs domain. The second factor, with a Cronbach's alpha of .829, retained all four items of one facet and was named SRPB domain. Both the personal beliefs and SRPB Scales had stronger Cronbach's alphas (.57 to .87 for personal beliefs and .84 for spirituality) than the initial pilot testing of the WHOQOL-HIV instrument study (WHOQOL-HIV Group, 2003a). The Personal Beliefs Scale also had a stronger Cronbach's alpha (.65-.82 for personal beliefs) than that of the Brazilian study (Zimpel & Fleck, 2007).

It is worth noting that the three facets that loaded on the personal beliefs domain were all HIV-specific items while the other four items that loaded on this SRPB were the only 4 items that assessed SRPB on the generic WHOQOL instrument. The 12 items were included by the WHOQOL-HIV Group as items relevant to PLWH (WHOQOL-HIV, 2003a). This difference may have caused the split of items into two factors in this domain. Further exploration of these items is necessary in order to determine how they blend together in PLWH. It would also be interesting to see if the 12 items conceptualized as specific to PLWH are relevant to uninfected persons.

The current study further assessed whether all of the domains would load on one factor, QOL, because they were conceptualized to assess the dimensions of QOL. This was to assess the possibility of a single QOL Scale. It is noteworthy that the published data did not reveal any studies that had taken this step, but it was a necessary step to take so as to comprehensively determine QOL. A second-order analysis was conducted on the eight resulting domains (physical, psychological, activity, medication independence, social relationships, environment, personal beliefs, and spirituality). Six domains (physical, psychological, activity, social relationships, environment, and personal beliefs) were loaded on one strong factor with a Cronbach's alpha of .896, and was named the Zambian WHOQOL-HIV Scale. The other two were loaded on the second factor, one was a positive factor (named the Zambian WHOHIV SRPB Scale) and the other was a negative factor (named the Zambian WHOHIV Medication Dependence Scale).

It is not clear whether the two scales accurately measure medication dependence and SRPB. The items need to be examined to determine whether they are comprehensive enough to measure the two concepts. For many people, SRPB are a source of comfort, well-being, security, meaning, sense of belonging, purpose, and strength (WHO, 2002). Also, as explained earlier, medication dependence had low scores on both the WHOQOL-HIV preliminary study and the Brazilian study. Hence, further refinement of these two domains is necessary. However, it will be important to conduct further studies to determine the relationship between QOL, medication dependence, and SRPB. There is a need to explore whether medication dependence and SRPB are predictors, mediators, or moderators of QOL. It may be intuitive to think that they are predictors or mediators of QOL. In a way, SRPB would help the individual come to terms with the reality of having HIV, which would lead to inner fulfillment and an ultimately better QOL. A better understanding of the effect of these concepts on QOL is desirable.

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Conclusion and Implications 

The Zambian WHOQOL-HIV Scale, Zambian WHOHIV Medication Dependence Scale, and Zambian WHOHIV SRPB Scale could be administered periodically as a follow-up study (e.g., every 6 months) to allow comprehensive monitoring of the disease process and to further validate the scales. Furthermore, participants could be allowed to self-administer the questionnaire to reduce administration time.

There is also a great need to reassess the WHOQOL-HIV instrument at different stages of HIV disease, given that there were differences in QOL in symptomatic and asymptomatic PLWH in the current study. The instrument had strong psychometric properties on a cross-sectional study. There is a need to assess the instrument over a period to determine the ability to detect QOL over time.

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Disclosures 

The authors report no real or perceived vested interests that relate to this article (including relationships with pharmaceutical companies, biomedical device manufacturers, grantors, or other entities whose products or services are related to topics covered in this manuscript) that could be construed as a conflict of interest. This study was funded in part by Margaret Namara Memorial Fund, World Bank. The authors acknowledge the work by Professor Zeller, who passed away before this article was finalized, MHSRIP.

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