Such instruments can be applied across different population groups with different language skills and require no or only little re-adaptation. One strategy to address the aforementioned challenges can be the use of language-independent questionnaires which are based on pictograms. This can be explained by a differential understanding of translated items between population groups. If language- and/or culture-specific instruments are used, cross-group comparability may be limited because of poor measurement equivalence. This can limit the methodological quality of such studies and compromise their validity. In the absence of alternatives, researchers occasionally use non-validated instruments or translate standardized questions “on the fly” during interviews.
The lack of available instruments thus contributes to migrants often being underrepresented in health research. As a consequence, certain population groups tend to be excluded from such studies. Given the broad cultural and linguistic heterogeneity of the population, this is usually not feasible in population-based research. Re-adapting instruments for migrants or revalidating them for previously unavailable languages requires a lot of financial, time and personnel resources and is also associated with methodical challenges. For smaller migrant populations such as Kurdish speakers, almost no validated instruments are available. This can greatly limit the validity of studies. For example, questionnaires validated for the population in Turkey are often incomprehensible or misleading for Turkish migrants residing in Germany. Because of differences in the use of the respective language and linguistic changes over time, these instruments usually cannot be administered to migrants without proper re-adaptation and re-validation. Although survey instruments frequently applied to assess HRQOL are readily available in different language versions, in most cases, they have only been adapted and validated for the languages and populations of the respective countries where migrants originate from. Since migrants may have a limited proficiency in the language of the country they reside in, mother-tongue instruments usually need to be used for survey purposes. In population-based studies, the use of such questionnaires is particularly challenging when researchers intend to survey migrants. These questionnaires have been translated and adapted for a large number of populations and, in part, may also differ in their underlying psychometric measurement models. HRQOL is usually assessed by means of standardized self- or interviewer-administered questionnaires, e.g., from the SF-36, EuroQol or WHOQOL family. For this purpose, HRQOL needs to be measured with high validity and reliability.
Identifying disparities in HRQOL between population groups can also help to inform healthcare strategies aiming to reduce deficits in the health system and to ensure patient-centered healthcare. Examples include the clinical testing of pharmaceuticals, the evaluation of therapies and healthcare concepts as well as benchmarking processes. Health-related quality of life (HRQOL) is a frequently studied patient-reported outcome in health research. Future studies need to examine its convergent and factorial validity. It is therefore considered to be superior to existing instruments for routine use in health research and practice. The PictoQOL is considered to allow a more accessible assessment and better comparability of HRQOL across different population groups regardless of their literacy level. Respondents found the use of an additional graphic layer in the form of symbols in addition to pictures helpful for interpretation. Some representations proved to be culturally sensitive and were adapted. Using a visual Likert scale, respondents indicate how much each situation applies to them. The PictoQOL consists of a pictorial representation of a total of 15 different situations. A mixed-methods design combining qualitative and quantitative methods was used, comprising 6 focus group discussions with a total of 17 participants, 37 cognitive interviews and a quantitative pretest with 15 individuals. The aim of the present study was to develop a pictorial questionnaire for the assessment of health-related quality of life (PictoQOL) and to examine its content validity and usability across three exemplary population groups of different origin residing in Germany (non-migrants, Turkish migrants and Arabic-speaking migrants).
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