Annals of Indian Academy of Neurology
: 2018  |  Volume : 21  |  Issue : 4  |  Page : 290--293

Validation of marathi version of stroke-specific quality of life

Suvarna Ganvir, Maheshwari Harishch, Chetana Kunde 
 Department of Neurophysiotherapy, DVVPF'S College of Physiotherapy, Ahmednagar, Maharashtra, India

Correspondence Address:
Prof. Suvarna Ganvir
DVVPF'S College of Physiotherapy, Ahmednagar - 414 111, Maharashtra


Background and Purpose: One of the most important patient-centered outcomes in patients with stroke is quality of life. Apart from physical affection, stroke affects cognitive, emotional language along with social functioning. Stroke-specific quality of life (SSQOL) is a measure to assess the quality of life in patients with stroke. The aim of this study is to investigate the reliability and validity of Marathi version of SSQOL in patients with stroke. Methodology: Translation of SSQOL in Marathi language was performed in accordance with the published guidelines. Validation of Marathi version of SSQOL was carried out by 130 patients with stroke with minimum 1 year of duration of stroke. Reliability was measured with the help of 36 volunteers diagnosed with stroke. Results: There were no major changes in the translated version, except in three items. Reliability was found to be 0.82 and validity was found to be 0.93. Floor and ceiling effects were found to be 11.3% and 6.3%, respectively. Conclusion: Marathi version of SSQOL is a valid, reliable instrument for measuring self-reported health-related quality of life in patients with stroke.

How to cite this article:
Ganvir S, Harishch M, Kunde C. Validation of marathi version of stroke-specific quality of life.Ann Indian Acad Neurol 2018;21:290-293

How to cite this URL:
Ganvir S, Harishch M, Kunde C. Validation of marathi version of stroke-specific quality of life. Ann Indian Acad Neurol [serial online] 2018 [cited 2021 Dec 8 ];21:290-293
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To assess the burden of disease, health-related quality of life (HRQOL) measurements are commonly used.[1] These measurements are also used to assess the impact of treatment methods[2] and to facilitate benchmarking, for example, for rehabilitation programs.[3] Cerebrovascular diseases were found to be the third leading cause of lost “disability-adjusted life years” in the developed countries.[4]

Disability caused by neurological conditions affects several areas of function; for example, for stroke, they include motor and sensory deficits, limitations in activities,[5],[6] and cognitive impairments such as reduced attention and memory and problems with language.[7],[8]

The stroke-specific quality of life (SSQOL) was first published in 1999 by Williams et al.[9] It contains 49 items and covers 12 different areas of the quality of life that may be affected by stroke. The 12 areas of the SSQOL are as follows: energy (E), family roles (FRs), language (L), mobility (M), mood, personality (P), self-care (SC), social roles (SRs), thinking (T), upper extremity function (UE), vision (V), and work/productivity (W). Each area can be scored separately, but a total score is also available. The possible range of all scales is from 1 to 5, where a lower value represents a lower HRQOL. The original scale is in English language.[9],[10] It is translated in Danish and German languages and has been found to be valid and reliable.

Efforts to produce reliable instruments capable of giving the same constructs across national borders in spite of cultural differences are needed. Any translated test method needs to be assessed for validity and reliability as if it were a new instrument.[10],[11],[12] The SSQOL is till now translated in Danish and German languages only.

For this scale to be used in India, it is necessary to convert it into Marathi. The objective of this study is, therefore, to translate and examine the cross-cultural validity of the SSQOL and to assess the validity of the Marathi version in both ischemic and hemorrhagic stroke survivors. The specific aims were (1) to translate the SSQOL and produce a cultural adaptation, (2) to examine the dimensionality of the SSQOL, (3) to assess its metric properties in terms of ceiling and floor effects, test–retest reliability, and internal consistency, and (4) to assess the validity of SSQOL-M.


The study was conducted in two phases. Phase 1 consisted of translation and cultural adaptation of Marathi SSQOL (SSQOL-M). Two translators were asked to independently translate the questionnaire from English to Marathi. These two translated versions were reviewed by a three-member panel of health professionals expert in the field of neuro-physiotherapy and fluent in both languages. Any questionable issues or language-related problems were solved by this panel. Finally, a single version was accepted after combining the items and coming to a consensus on each item in the Marathi scale. It was then retranslated by two health professionals who were fluent in English. These two translators were unaware of the previous translation. Both translated versions were again reviewed by the panel, and it was then compared with the original questionnaire. Any specific words which did not match in two versions were discussed by the committee and the appropriate word was used in the questionnaire. Marathi-translated version was then given to a pilot group of 36 hemiplegics for scoring and prevalidation of the questions. After receiving the questionnaire from them with their specific inputs about the structuring of each question, few modifications were done. This was the final prevalidated version of the questionnaire.

Phase 2 – Institutional Ethics Committee approval was sought and received prior beginning this phase. This prevalidated questionnaire was then given to the study participants carefully selected according to the inclusion and exclusion criteria. Patients diagnosed with stroke and currently receiving physiotherapy or who had received it in the past, in the Physiotherapy Department of Vikhe Patil Memorial Hospital, were selected for the study. Exclusion criteria were as follows: Patients with subarachnoidal hemorrhage, traumatic brain injury, global aphasia, inability to read or write Marathi before the stroke, dementia, verified psychiatric disorders, and other associated diseases with serious impact on the patient's functional level. For retesting, 39 patients volunteered. They were instructed thoroughly about the readministration of questionnaire. They were again given a questionnaire by the first author after 7 days for test–retest reliability. Short form-36 (SF-36) was also administered as a standard measure of quality of life. Scores of functional independence measure (FIM) were also recorded.

To examine the dimensionality of the SSQOL, we used the same method as that used in the original study factor analyses, with principal component analysis and varimax-rotation.[12],[13] To assess the metric properties for the SSQOL ceiling effects, we counted the percentage of patients who scored 5 for each scale, and to determine the floor effects, we counted the percentage of patients who scored 1. For the test–retest reliability, the intraclass correlation coefficient (ICC) 24 was chosen because it accounts for constant differences. To examine the internal consistency, Cronbach's alpha was calculated. To assess the validity, the SSQOL was correlated with SF-36 and FIM values using the Spearman's rank correlation coefficient because of the unknown scales of measurement of the SSQOL.

Statistical analysis

Demographic information was noted and descriptive analysis was carried out. It included information related to age, gender-wise distribution, hand dominance, side of affection, previous occupation duration and type of stroke, family, and work status.

Factor analysis of the translated questionnaire was performed. Floor and ceiling effects were studied by calculating the proportions of minimum and maximum score. Internal consistency was measured by calculating Cronbach's alpha for each subscale. To assess the validity, the SSQOL was correlated with SF-36 and FIM values using the Spearman's rank correlation coefficient because of the unknown scales of measurement of the SSQOL. For retesting, Spearman's rank-order correlation (rs) was used to calculate the magnitude of the relationship between the first and the second administration. An rs of 0.80 was set as level of acceptance for stability of the SSQOL-M.


Of 130 participants who were included in the study, 45% were female and 55% were male. The median age was 61 years (range 45–72 years). [Table 1] describes the characteristics of participants. Thirty-six participants returned the retest. The mean length of stay in the hospital was 45.5 days (standard deviation [SD] = 21.3). The mean discharge FIM was 91.6 (SD = 13.4). At the time of the survey, the mean FIM was 92.7 (SD = 19.97).{Table 1}

Floor and ceiling effect analyses showed that less than half of the respondents chose the maximum score and few chose the minimum score indicating better quality of life. Only language and communication had a considerable ceiling effect of 63.8%. The Danish version of SSQOL showed internal consistency, as measured with Chronbach's alpha, with coefficients ranging from 0.81 to 0.94 [Table 2]. The criterion validity of the SSQOL total score and also that of the subscales was examined by comparison of the associations to SF-36 and FIM. All associations with the SF-36 and the FIM are shown in [Table 1]. The total SSQOL scores have moderate-to-high associations between the two SF-36 component scales as well as the FIM scales. Item-wise analysis revealed that four items correlated significantly higher with three other domains than with their own: item work 2: “Do you have a difficulty in completing a task?” which correlated higher with the domains SC and UE function. Similarly, item self-care 3: “Do you need help while bathing?” correlated higher with the domains mobility and work; and item mobility 5: “Do you have trouble while walking?” correlated higher with the domains role in the society. Furthermore, interest item 4: “I have less confidence in myself” also correlated well with work.{Table 2}

Retesting showed acceptable stability, r = 0.80, in eight domains. Four domains, namely personality, language, FRs, and SRs, showed r = 0.71, 0.65, 0.71, and 0.76, respectively. Two domains (UE function and mobility) showed statistically significant difference between the first and second tests [Table 2].

In the returned SSQOL-DK questionnaires, there was a missing item rate of 6%. Item SR6 “I had sex less often than I would like” was most frequently missed with a missing rate of 20.2%. Fourteen respondents had not filled in this item. Ten of these were single women above 63 years.


This study investigated the psychometric properties of a transcultural version of an instrument. Overall, the performance of the SSQOL-M is very similar to that of the original instrument, which indicates a successful translation.

Test–retest reliability was satisfactory; patients displayed correlations between 0.71 and 0.96 on SSQOL questionnaire domains between the first test and the second test, which was taken 1 week after the first [Table 2]. For the American version of the SSQOL questionnaire, the correlation between an initial evaluation and a reevaluation 2 h later was 0.92.[13] Spanish version study has reported test–retest stability to be around 0.8 when it was retested within a week[14] (Spanish study). The Danish version reported test–retest correlations between 0.65 and 0.99, with an assessment interval of 1–2 weeks.[12] Meanwhile, patients who took the German version of the SSQOL questionnaire had test–retest correlations of 0.69, with an assessment interval of 1 year.[15] The results showed that a shorter test–retest interval increased the test–retest correlation and yielded optimal results (rs ≥ 0.8), thereby indicating good stability.

Validity of SSQOL-M is found to be good. High association is found between FIM motor scale and physical function scale of SF-36 with that of SSQOL-M. The items used in these scales are similar.

Validity scores of SSQOL questionnaire ranged between 0.07 and 0.84 for both scales, that is, SF-36 and FIM [Table 3]. This indicates that there are adequate linear relationships between certain SSQOL questionnaire domains and their respective comparison scales (SF-36 and FIM). Similar results are reported by Williams et al.[11] and Muus and Ringsberg.[12] Activities domain on SSQOL has a strong linear relationship with physical component summary of SF-36, which indicates that good physical functioning helps patient to perform the activities in a better way, and hence, physical activity should be encouraged. The energy domain of the SSQOL questionnaire, however, had a less linear relationship with the vitality subscale of SF-36 than that found by Williams et al. and Muus and Ringsberg. This indicates that the energy domain is described more distinctly by the generic scale (SF-36) than by the specific SSQOL scale in the present sample.{Table 3}

In our study, there was moderate floor effect. It may be due to the fact that all kinds of patients were included in the study. Severely disabled patients were also included along with mild to moderate. Hence, the scale might not be able to represent severely disabled patients. Furthermore, the item 1 (I do not move out of house as before) in the role of society was scored less by maximum participants. On asking leading question about the possible reason behind this, most of the participants replied that there are infrastructural barrier. Furthermore, the item 1 – feel fatigued most of the time – scored less. This may due to the fact that there is reduced functional capacity. Due to reduced physical ability, patients do not perform majority of the activities appropriate to their age. The number of activities are more in this component as compared to other components, and in patients severe disability, activities are maximally affected as compared to mild or moderately affected individuals. The ceiling effects are mild to moderate, because the scale contains more specific items related to stroke as compared to other scales. However, the effect is diluted due to the presence of certain items such as vision and cognitive affection which are not so commonly seen in patients with stroke.


From the study, it can be concluded that Marathi version of SSQOL is a valid and reliable tool to assess the quality of life in patients with stroke.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Hopman WM, Verner J. Quality of life during and after inpatient stroke rehabilitation. Stroke 2003;34:801-5.
2Buck D, Jacoby A, Massey A, Ford G. Evaluation of measures used to assess quality of life after stroke. Stroke 2000;31:2004-10.
3Samsa G, Edelman D, Rothman ML, Williams GR, Lipscomb J, Matchar D, et al. Determining clinically important differences in health status measures: A general approach with illustration to the health utilities index mark II. Pharmacoeconomics 1999;15:141-55.
4Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global burden of disease study. Lancet 1997;349:1436-42.
5Jørgensen HS, Nakayama H, Raaschou HO, Vive-Larsen J, Støier M, Olsen TS, et al. Outcome and time course of recovery in stroke. Part I: Outcome. The Copenhagen Stroke Study. Arch Phys Med Rehabil 1995;76:399-405.
6Zorowitz RD. Neurorehabilitation of the stroke survivor. Neurorehabil Neural Repair 1999;13:83-92.
7Srikanth VK, Thrift AG, Saling MM, Anderson JF, Dewey HM, Macdonell RA, et al. Increased risk of cognitive impairment 3 months after mild to moderate first-ever stroke: A community-based prospective study of nonaphasic english-speaking survivors. Stroke 2003;34:1136-43.
8Kase CS, Wolf PA, Kelly-Hayes M, Kannel WB, Beiser A, D'Agostino RB, et al. Intellectual decline after stroke: The Framingham study. Stroke 1998;29:805-12.
9Williams LS, Weinberger M, Harris LE, Clark DO, Biller J. Development of a stroke-specific quality of life scale. Stroke 1999;30:1362-9.
10Yu DS, Lee DT, Woo J. Issues and challenges of instrument translation. West J Nurs Res 2004;26:307-20.
11Williams LS, Yilmaz EY, Lopez-Yunez AM. Retrospective assessment of initial stroke severity with the NIH stroke scale. Stroke 2000;31:858-62.
12Muus I, Ringsberg KC. Stroke specific quality of life scale: Danish adaptation and a pilot study for testing psychometric properties. Scand J Caring Sci 2005;19:140-7.
13Cid-Ruzafa J, Damián-Moreno J. Disability evaluation: Barthel's index. Rev Esp Salud Publica 1997;71:127-37.
14Cruz-Cruz C, Martinez-Nuñez JM, Perez ME, Kravzov-Jinich J, Ríos-Castañeda C, Altagracia-Martinez M. Evaluation of the stroke-specific quality-of-life (SSQOL) scale in Mexico: A preliminary approach. Value Reg Issues 2013;2:392-7.
15Ewert T, Stucki G. Validity of the SS-QOL in Germany and in survivors of hemorrhagic or ischemic stroke. Neurorehabil Neural Repair 2007;21:161-8.