The Quebec Questionnaire of Representations related to Work Disability (QRWoD): Cross-cultural adaptation,validity and reliability in French chronic low back pain workers

Abstract

BACKGROUND:

Addressing chronic low back pain (cLBP) from the point of view of representation allows better understanding the behaviors associated with it and thus improve its medical and socio-occupational management. The Quebec Questionnaire of Representations related to Work Disability (QRWoD) proposes an evaluation of 9 dimensions of the cLBP-related representation.

OBJECTIVE:

To translate and adapt the QRoWD to French language and assess its validity and reliability in French cLBP workers on prolonged sick leave.

METHODS:

A prospective study was conducted from March 2017 to April 2018 in the Department of occupational health of the University Hospital of Angers, France. The QRWoD is a self-administered questionnaire (87 items) which assesses Identity, Acute/Chronic duration, Consequences, Personal Control, Treatment Control, Cyclical Timeline, Coherence, Emotional Representation and Causes dimensions. The Internal consistency (Cronbach’s $\alpha$ ) and the convergent validity (Pearson correlations) in comparison to validated instruments for each dimension were assed.

RESULTS:

Fifty French workers (29 men, 43 $\pm$ 9.1 years, 293.6 $\pm$ 173.0 days of work absence) were included. The internal consistency (all $\alpha>$ 0.7) and the convergent validity (all $r^{2}>$ 0.25, $p<$ 0.01) of each dimension were very satisfactory except for the Cyclical Timeline dimension.

CONCLUSIONS:

The French version of the QRoWD seems to be valid and relevant among the target population.

Keywords

Chronic low back pain cross-cultural adaptation dimensions representation validity work disability

1. Introduction

Chronic low back pain (LBP) is a major public and occupational health problem, particularly because of the work disability it generates. The longer a worker is off work with LBP, the lower are his chances of ever returning to work [1, 2, 3]. It is now well recognized that in the presence of persistent pain, the perception of work disability related to pain is a major factor that influences the duration of the absence. Numerous psychosocial factors have been associated with work disability following LBP: fear of movement [4], recovery expectations [5, 6], perception of incapacity [7], pain catastrophizing [8] and psychological distress [9] are among the psychological factors most commonly cited [10, 11]. These unhelpful beliefs may lead to behaviors that are poorly adapted to reducing the work disability following LBP [10, 12, 13]. In other words, the way in which the worker understands his problem (representation) influences his adaptation strategies and consequently his return to work [14].

The representation of the disease is defined as the set of thoughts, ideas, beliefs and attitudes about the nature of the disease; it is constructed by the person to make sense of his illness and is associated with the adoption of behaviors aimed at adapting or controlling the problem [12, 14, 15, 16]. The cognitive representation is organized in five core components which consist of beliefs regarding: (1) symptoms and diagnosis (Identity), (2) elements that provoked illness (Causes), (3) negative effects related to illness (Consequences), (4) expected duration of illness (Timeline) and (5) effectiveness of treatment to recover from illness or possibilities of having personal control on illness (Cure/Control) [14].

Addressing the disease from the point of view of representation makes it possible to understand the behaviors associated with it and thus improve its medical and socio-occupational management [17, 18]. In the context of management combining retraining with return to work/job retention support for chronic LBP workers (tertiary care), the evaluation of representation is therefore crucial [13, 19].

Tools to assess the patient’s illness representation exist, but they are mainly developed in a medical context rather than in a disability prevention aim [20]. Furthermore, qualitative studies among persistent LBP revealed that a number of workers did not define themselves as being “ill”, but rather in an “intermediate state” between illness and health [21]. Questionnaires assessing representation must therefore be adapted prior to their use among this category of patients. A review of assessment tools indicated that the Revised Illness Perception Questionnaire (IPQ-R) appeared relevant because of its factorial structure and its superior psychometric properties: all the subscales demonstrated good internal consistency and the dimensions generally showed good stability [10, 20]. The Quebec translation of the original IPQ-R, named Questionnaire of Representations related to Work Disability, show equivalent psychometric properties [11]. For these reasons, the (QRWoD) was selected for a French adaptation.

The aim of this study was to adapt the Quebec (QRWoD) to a French version and assess the relevance and the validity of the French named Questionnaire sur les Représentations liées l’Incapacité au Travail (QRIT) [in French].

2. Methods

2.1 Study design

A cross-sectional study was conducted from March 2017 to April 2018 in the Department of occupational health of the University Hospital of Angers, France in collaboration with the Action Center for Prevention and Rehabilitation of Disability at Work (CAPRIT) team of the Sherbrooke University, Canada. The Quebec team was the one who conducted the Quebec translation from the Revised Illness Perception Questionnaire (IPQ-R) to the Questionnaire of Representations related to Work Disability (QRWoD) [11]. Ethical approval has been granted by the Ethics Committee of Angers, France (number 2016/82) (http://www.ccpprb-angers.fr.st) on 14 September 2016.

2.2 Translation

A French translation of the Quebec version of the (QRWoD) was developed by a group of four French (1 rehabilitation physician, 1 psychologist and 1 rheumatologist specialized in occupational health) and Quebec experts (1 occupational therapist) clinicians and researchers, in order to develop the French version of the Questionnaire of Representations related to Work Disability (QRIT). All these professionals were specialized in the work disability field.

Table 1
Variables and instruments selected for the convergent validity of each dimension

Variable	Instruments	Description
Fear of movement	Fear Avoidance and Belief Questionnaire (FABQ)	16 items rated on 6-point Likert scale assessing the fear of triggering pain when moving or working and divided in 2 sub-scores: physical activity and work
Pain catastrophizing	Pain Catastrophizing Scale (PCS)	13 items rated on a 5-points frequency scale describing thoughts and feelings that individuals may experience when they have pain
Psychological distress	Hospital Anxiety and Depression scale (HAD)	14 items rated on a 4-point frequency scale assessing anxiety and depressive disorders and divided in 2 sub-scores: anxiety and depression
Impact of LBP on function	Oswestry Disability Index (ODI)	10 sections including 6 situations of growing disability and assessing the impact of LBP on function
Repercussions of LBP on the quality of life	Dallas Pain Questionnaire (DPQ)	16 items rated on linear scales cut into 6 segments (0 to 100%) on which the participant is asked to indicate the place that best corresponds to his current situation and divided in 4 sub-scores: impact on daily activities, impact on work and leisure activities, impact on anxiety and/or depression, impact on sociability
Self-efficacy with regard to pain management	Pain Self-Efficacy Questionnaire (PSEQ)	10 items rated on a 6-point Likert scale assessing how the participant is confident to do things despite the pain
Pain intensity	Visual Analog Scale (VAS)	100 mm line marked at each end with labels (no pain; worst pain imaginable) on which the participant is asked to indicate the point representing his/her pain intensity
Mystery and pain duration	Pain Beliefs and Perceptions Inventory (PBPI)	16 items rated on a 4-point Likert scale assessing beliefs regarding pain, distributed among 3 dimensions: Mystery, Pain duration an Self-blame
Illness representation	Implicit Models of Illness Questionnaire (IMIQ)	45 items rated on a 5-point Likert scale assessing illness representation based on the Common Sense Model of self-regulation of health and illness and divided in 4 dimensions: consequences, responsibility, curability and variability

2.3 Cultural adaptation

A pre-test phase was then conducted with a sample of the target population ( $n=$ 15) to assess items clarity of the QRIT. This phase consisted of scoring the clarity of each item ( $n=$ 87) on a 7-level Likert scale (1 $=$ not clear, 7 $=$ quite clear). In total, six words or expressions were modified following the pre-test phase.

The second phase of the study was conducted with a larger sample ( $n=$ 50), modeled on the validation process of the Quebec tool [10, 11] to assess the relevance and the validity of the 9 dimensions of the QRIT in comparison to validated instruments for each dimension. This phase consisted of scoring the 87 items as well as the other selected instruments for the construct validity. The rating was reversed for some negative items. The second phase participants were different from the first phase ones.

2.4 Questionnaires

The QRIT is a self-administered questionnaire composed of 87 items divided into 3 sections (plausible symptoms, opinion on current state of health, plausible causes) which allows exploring 9 dimensions of chronic LBP-related representation: Identity i.e. declared symptoms (16 plausible symptoms), Acute/Chronic duration (7 items), Consequences (9 items), Personal Control on LBP (8 items), Treatment Control i.e. expectations of treatment efficiency (8 items), Cyclical Timeline (4 items), Coherence of the symptoms (7 items), Emotional Representation (8 items) and Causes (20 plausible causes) [10, 11]. Each item was scored on a five-level Likert scale (1 $=$ strongly disagree, 5 $=$ strongly agree) and a score was calculated for each dimension.

Each of the 9 dimensions was analyzed separately by an independent score. For construct validity, the following nine reliable and French-validated tools were selected as they document one or several dimensions of the representation (Table 1): The Fear Avoidance and Belief Questionnaire (FABQ) [22], the Dallas Pain Questionnaire (DPQ) [23], the Visual Analog Scale (VAS), the Hospital Anxiety and Depression scale (HAD) [24], the Pain Catastrophizing Scale (PCS) [25], the Oswestry Disability Index (ODI) [26], the Pain Self-Efficacy Questionnaire (PSEQ) [27], the Implicit Models of Illness Questionnaire (IMIQ) [28], the Pain Beliefs and Perceptions Inventory (PBPI) [29].

2.5 Participants

The target population was composed of workers on sick leave due to chronic LBP and participating in a multidisciplinary evaluation in order to include them in a work rehabilitation program. Inclusion criteria were: being aged between 18 to 60 years, having more than 3 months of absence from work related to LBP. Workers unable to understand and/or read French, suffering from a LBP related to a specific pathology (infectious, inflammatory, cancerous, etc.), or presenting major psychiatric problems as indicated in their medical record were excluded.

Participants were recruited from a French chronic LBP care-network involved in medical and occupational issues. This network includes a multidisciplinary clinic conducted by a rehabilitation physician, an occupational physician, a psychologist and an occupational health nurse. Those who agreed and signed the consent form where then asked to complete the French adapted questionnaire (QRIT) and nine-related instruments assessing separate components of the representation, which took approximatively one hour.

Sample size was calculated for a multiple regression analysis by an a priori power analysis performed with the G*Power 3.1.2 software [30]. In order to identify at least 3 significant associations ( $r>$ 0.35) with a power value of 80% and an $\alpha$ level of 5%, a minimum of 36 participants were required [10].

2.6 Statistical analyses

Statistical analyses were performed with the SPSS ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}{\textregistered}}$ software version 22.0. Frequencies and central tendency measures were calculated to describe the sample’s profile. Furthermore, frequencies to which symptoms and causes were endorsed by participants were calculated. Internal consistency was estimated by calculation of Cronbach’s $\alpha$ for each component of the representation. To assess convergent validity, a Person correlation matrix was obtained to identify the significant association between dimensions of the QRIT and the selected instruments measuring separate components of the representation (independent variables).

3. Results

3.1 Participants

Among workers who met the inclusion criteria, a total of 50 participants were offered the opportunity and accepted to participate in this study. Complete data were obtained for the 50 participants. The sample consisted of 29 men and 21 women, with a mean age of 43 $\pm$ 9.1 years and a mean duration of work absence of 293.6 $\pm$ 173.0 days. Most of them were on manual work (64%) i.e. involving sustained or repeated postures, heavy workloads, etc., two percent were on sedentary workstation, and 32% on mixed work. Ninety four percent were on an open-ended contract of work in the public or private sector and 58% had five years or more of length of service in the current job. Regarding LBP, one third of the participants suffered from LBP since less than two years and 44% since more than five years. Twelve participants were recognized as an occupational injury for LBP and six as an occupational disease. Finally, 22 participants had a history of depression and 11 had a history of spine surgery (Table 2).

Table 2
Characteristics of participants ( $n=$ 50)

Categorical variables	Frequency (%)
Gender
Male	29 (58)
Female	21 (42)
Type of work
Manual	32 (64)
Non-manual	2 (4)
Mixed	16 (32)
Employment contract
Open-end	47 (94)
Fixed-term	2 (4)
Business for own self	1 (2)
Length of service (years)
0 to 5	13 (26)
5 to 10	17 (34)
$>$ 10	12 (24)
Occupational injury or disease
Occupational injury	12 (24)
Occupational disease	6 (12)
Length of LBP
6 to 12 months	7 (14)
12 to 24 months	10 (20)
2 to 5 years	11 (22)
$>$ 5 years	22 (44)
History of spine surgery
Yes	11 (22)
No	39 (78)
History of depression
Yes	22 (44)
No	28 (56)

3.2 Identity and Causes dimensions

As shown in Table 3, among the 16 plausible symptoms listed in the first part of the questionnaire, 10 symptoms appeared to be much more frequently declared by participants (56 to 98% of the sample). That supports the pertinence of the Identity dimension intended for a population suffering from chronic LBP. Similarly, frequency calculations for the Causes dimension revealed that 10 causes were also endorsed by a significant proportion of the sample (more than 30%), again supporting their pertinence for a population in situation of work disability related to chronic LBP.

Table 3
Endorsement frequencies of Identity and causes dimensions’ items ( $n=$ 50)

Identity	Frequency (%)	Causes	Frequency (%)
Pain	49 (98)	Stress or troubles	23 (46)
Nausea	7 (14)	Heredity, family history	10 (20)
Weight gain	24 (48)	Diet	6 (16)
Tiredness	44 (88)	Bad luck	19 (38)
Joints stiffness	38 (76)	Poor medical care in the past	14 (28)
Headaches	18 (36)	Own behavior	16 (36)
Sleeping troubles	36 (72)	State of mind	8 (16)
Vertigo	11 (22)	Family problems	14 (28)
Lack of strength, weakness	35 (70)	Too much work	25 (50)
Changes in physical sensation	19 (38)	Emotional state	16 (32)
Decrease of physical capacity	45 (90)	Aging	15 (30)
Mood changes	34 (68)	Alcohol consumption	4 (8)
Numbness	28 (56)	Tabaco consumption	5 (10)
Attention/memory problems	21 (42)	Accident or injury	17 (34)
Lack of endurance	40 (80)	Temperament, character	15 (30)
Fears	26 (52)	Anterior physical condition	20 (40)
		Work environment	36 (72)
		Fatality/destiny	9 (18)
		Another’s error or negligence	13 (26)
		Delays in healthcare system	14 (28)

Table 4

Descriptive results for each dimension ( $n=$ 50)

Dimension [range of possible score]	Min.	Max.	Mean ${}^{*}$	SD	$\alpha$ Cronbach
Identity [0–16]	2	16	9.88	3.40	0.80
Acute/Chronic [7–35]	11	31	23.32	4.89	0.76
Consequences [9–45]	10	44	29.36	7.33	0.88
Personal Control [8–40]	18	39	26.06	4.63	0.78
Treatment Control [8–40]	16	35	27.04	4.17	0.75
Coherence [7–35]	12	33	21.36	4.65	0.73
Cyclical Timeline [4–20]	4	20	13.74	3.75	0.77
Emotional Representation [8–40]	10	40	27.10	8.00	0.92
Causes [0–20]	28	90	52.06	12.99	0.86

${}^{*}$ Scores for each dimension are normally distributed (Kolmogorov-Smirnov Test $>$ 0.05).

Table 5

Convergent validity of the QRWoD- $f$ with related instruments ( $n=$ 50)

Dimension	Adjusted $r^{2}$ ( $p$ )	Variable(s) included in the final regression model (instrument)
Identity	0.46 ( $p<$ 0.01)	Impact of LBP on function (ODI)
Acute/Chronic duration	0.39 ( $p<$ 0.01)	Pain intensity (VAS)Fear of movement (FABQ)Pain catastrophizing (PCS)
Consequences	0.43 ( $p<$ 0.01)	Self-Efficiency with regard to LBP management (PSEQ)
Personal Control	0.30 ( $p<$ 0.01)	Mystery and pain duration (PBPI)Illness representation (IMIQ)
Treatment Control	0.21 ( $p<$ 0.01)	Mystery and pain duration (PBPI)
Coherence	0.25 ( $p<$ 0.01)	Mystery and pain duration (PBPI)
Cyclic Timeline	0.12 ( $p<$ 0.01)	No significant association except for gender
Emotional Representation	0.67 ( $p<$ 0.01)	Pain intensity (VAS)Self-Efficiency with regard to LBP management (PSEQ)Pain catastrophizing (PCS)
Causes	0.44 ( $p<$ 0.01)	Psychological distress (HAD)Illness representation (IMIQ)

3.3 Internal consistency

Cronbach’s $\alpha$ coefficients calculated for each dimension separately indicated very satisfactory consistency for each dimension. Indeed, $\alpha$ coefficient were superior to the 0.6 threshold identified by Stafford and Bodson [31] and were all between 0.7 and 1, indicating good to excellent internal consistency among the items within the scale [32] (Table 4).

3.4 Convergent validity of each dimension of the QRIT

Moderate to strong correlation were found for each dimension with the nine theoretically-related variables, as shown in Table 5, suggesting satisfactory convergent validity. The only exception was the Cyclical Timeline dimension for which no correlation was found excepted for gender ( $r^{2}=$ 0.12). Furthermore, The Dallas Pain Questionnaire (DPQ) was not significantly associated to any of the QRIT dimension following the regression analysis. Interestingly, the correlation matrix showed that self-efficacy related to chronic pain management (PSEQ) was not related to the Personal Control dimension as expected, but rather than to the Emotional Representation ( $r^{2}=$ 0.67) and the Consequences ( $r^{2}=$ 0.43) dimensions. Similarly, functional disability related to LBP (ODI) was not related to the Consequences dimension as expected, but rather than to Identity ( $r^{2}=$ 0.46).

4. Discussion

This study presents the cross-cultural adaptation and cross-cultural validation of a Quebec questionnaire assessing representations related to work disability in French chronic LBP workers. Results of the pre-test were in favor of global clarity of the QRIT. The very satisfactory internal consistency suggested that each item belongs to the right dimension. The symptoms and causes explored by the QRIT were in agreement with those usually reported by the target population. Convergent validity analyses revealed satisfactory correlation with independent variables assessing similar concepts. The Cyclical Timeline dimension was the only one that was not associated to any other instrument. This result is consistent with those from a previous research on the Quebec version, in which the Cyclical Timeline dimension did not correlate with any other tool. This could suggest that the QRoWD and the QRIT are the only self-administered questionnaires that assess the cyclical aspect of LBP.

The strengths of this study were the close collaboration between the Quebec team who developed the original version of the QRoWD and the French team who conducted the study, especially for the adaptation process. All the participants were selected among a clinic specialized in prolonged disability at work related to chronic LBP. Instruments used were all self-administered questionnaires to better assess subjective data and avoid interpretation bias. All the questionnaires were entirely completed through a dedicate time for participants and the check by an assistant, to avoid missing data.

Our results are quite comparable to those obtained for the validation of the Quebec version [10, 11]. However, even if the measured variables were the same, the tools used to assess them differed for some: fear of movement was assessed by the Fear Avoidance and Belief Questionnaire (FABQ) instead of the Tampa Scale for Kinesiophobia (TSK), psychological distress was assessed by the Hospital Anxiety and Depression scale (HAD) instead of the Psychological Distress Index 14 items (PDI-14), perception of incapacity was assessed by the Oswestry Disability Index (ODI) instead of the Pain Disability Index (PDI) and self-efficacy with regard to pain management was assessed by the Pain Self-Efficacy Questionnaire (PSEQ) instead of the Self-Efficacy for Return to Work Scale (SERWS). These instruments were selected according to their superior psychometric properties and their availability in a validated French version.

Our results showed very interesting clinical implication in the work disability field. Concerning the Identity dimension, results supported that a high number of symptoms endorsed by participants is more strongly associated to LBP related disability than to pain intensity (VAS). Identity dimension was associated with psychological distress in the Quebec population. That might be supported by the usual association between pain and psychological distress among people with chronic LBP [33, 34] but we did not found this result in the French sample. Our findings may suggest the hypothesis that the use of a scale assessing LBP-related disability (ODI) may be more comprehensive of the profile presented by individuals in a prolonged work disability situation. However, LBP-related disability was not significantly associated with the Consequences dimension which seemed to be well associated with self-efficacy related pain management. The Consequence dimension was not associated either with LPB repercussions on activities of daily living (DPQ) which include occupational and leisure activities items.

The Pain Self-Efficacy Questionnaire (PSEQ) was initially selected to assess whether an association would occur with the Personal Control dimension of the QRIT. Self-efficacy theory is, by definition, the person’s level of confidence to perform specific behaviors under particular circumstances [35]. The absence of association between these two variables in this sample may be explained by the multifactorial concept of prolonged work disability which cannot be only related with self-efficacy beliefs. Our results rather showed Personal Control association with beliefs and perceptions related to pain (PBPI) and with illness representation (IMIQ). On the other hand, self-efficacy related to pain management was associated with the Emotional Representation dimension. That support the hypothesis that personal control is mainly influenced by illness-related believes, perceptions and representations.

As expected, the Emotional Representation was strongly associated with pain catastrophizing (PCS) but not with psychological distress (HAD) or illness representation (IMIQ). Those results suggested that the main perceived emotions are influenced by catastrophic thoughts in prolonged disability individuals. Indeed, chronic LBP and the resulting chronic disability are well related with catastrophic thoughts [36, 37]. Those results are comforted by the association between the chronic feature of LBP and pain catastrophizing (PCS).

5. Conclusion

A French version of the QRoWD (the QRIT) has been validated among a sample of the target population i.e. workers in prolonged disability situation related to LBP. Very satisfactory internal consistency and convergent validity support the use of this tool in clinic. The QRIT would help French clinicians to evaluate nine dimensions of the representation related to prolonged work disability in LBP workers. This evaluation would be very helpful to better understand workers’ beliefs and behaviors likely to hinder their rehabilitation process and their return to work. The use of the QRIT as part of a systematic evaluation process will assist clinicians to better identify beliefs leading to behaviors of their patients, in order to put forward pragmatic management strategies that will coincide with workers’ representation [19, 20, 38].

Footnotes

Acknowledgments

This study was made possible through the commitment of workers who accepted to spend the time of completing questionnaires. The authors would also like to thank Emilie Montoya for her help with the data collection and Sylvaine Jego for her contribution to the statistical analyses.

Conflict of interest

The authors report no conflict of interest.

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. Intercultural communication in health care: challenges and solutions in work rehabilitation practices and training: a comprehensive review. Disabil Rehabil 2013 Jan; 35(2): 153-63.

The Quebec Questionnaire of Representations related to Work Disability (QRWoD): Cross-cultural adaptation,validity and reliability in French chronic low back pain workers

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Methods

2.1 Study design

2.2 Translation

Table 1 Variables and instruments selected for the convergent validity of each dimension

2.4 Questionnaires

2.5 Participants

2.6 Statistical analyses

3. Results

3.1 Participants

Table 2 Characteristics of participants ( n = 50)

Table 3 Endorsement frequencies of Identity and causes dimensions’ items ( n = 50)

3.4 Convergent validity of each dimension of the QRIT

4. Discussion

5. Conclusion

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Variables and instruments selected for the convergent validity of each dimension

Table 2
Characteristics of participants ( $n=$ 50)

Table 3
Endorsement frequencies of Identity and causes dimensions’ items ( $n=$ 50)