utilization and content validity of the swedish version of the volitional questionnaire (vq-s)

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ARTICLE Utilization and Content Validity of the Swedish Version of the Volitional Questionnaire (VQ-S) Kristin Alfredsson ˚ Agren, M.Sc.OT, Reg OT Anette Kjellberg, PhD, M.Sc.OT. ABSTRACT. The aim of this study was to examine the utility and content validity of the Swedish version of the Volitional Questionnaire (VQ-S). The participants in this study were thirteen occupational ther- apists selected because they worked with clients for whom the VQ-S is appropriate (in this case, adults with intellectual impairments) and because they had knowledge of the Model of Human Occupation. These participants completed a demographic questionnaire at the beginning of the study. Each therapist then used the VQ-S a total of six times and after each time they completed a questionnaire concerning the Kristin Alfredsson ˚ Agren is Lecturer, Department of Social and Welfare Studies, Faculty of Health Sciences, Link¨ oping University, Norrk¨ oping, Sweden. Anette Kjellberg is Assistant Professor, Department of Social and Welfare Studies, Faculty of Health Sciences, Link¨ oping University, Norrk¨ oping, Sweden. Address correspondence to: Kristin Alfredsson ˚ Agren, Department of Social and Welfare Studies, Faculty of Health Sciences, Link¨ oping University, Norrk¨ oping, Sweden, SE- 60174 Norrk ¨ oping, Sweden (E-mail: [email protected]). Occupational Therapy in Health Care, Vol. 22(2–3), 2008 Available online at http://www.haworthpress.com/web/OTHC C 2008 by Informa Healthcare USA, Inc. All rights reserved. doi: 10.1080/07380570802135456 163 Occup Ther Health Downloaded from informahealthcare.com by York University Libraries on 11/20/14 For personal use only.

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Page 1: Utilization and Content Validity of the Swedish Version of the Volitional Questionnaire (VQ-S)

ARTICLE

Utilization and Content Validity of theSwedish Version of the Volitional

Questionnaire (VQ-S)

Kristin Alfredsson Agren, M.Sc.OT, Reg OTAnette Kjellberg, PhD, M.Sc.OT.

ABSTRACT. The aim of this study was to examine the utility andcontent validity of the Swedish version of the Volitional Questionnaire(VQ-S). The participants in this study were thirteen occupational ther-apists selected because they worked with clients for whom the VQ-Sis appropriate (in this case, adults with intellectual impairments) andbecause they had knowledge of the Model of Human Occupation. Theseparticipants completed a demographic questionnaire at the beginningof the study. Each therapist then used the VQ-S a total of six timesand after each time they completed a questionnaire concerning the

Kristin Alfredsson Agren is Lecturer, Department of Social and Welfare Studies,Faculty of Health Sciences, Linkoping University, Norrkoping, Sweden.

Anette Kjellberg is Assistant Professor, Department of Social and Welfare Studies,Faculty of Health Sciences, Linkoping University, Norrkoping, Sweden.

Address correspondence to: Kristin Alfredsson Agren, Department of Socialand Welfare Studies, Faculty of Health Sciences, Linkoping University, Norrkoping,Sweden, SE- 60174 Norrkoping, Sweden (E-mail: [email protected]).

Occupational Therapy in Health Care, Vol. 22(2–3), 2008Available online at http://www.haworthpress.com/web/OTHCC© 2008 by Informa Healthcare USA, Inc. All rights reserved.

doi: 10.1080/07380570802135456 163

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164 OCCUPATIONAL THERAPY IN HEALTH CARE

utility and content validity of the instrument. After having adminis-tered the instrument six times they completed a third questionnairethat assessed their perceptions of the VQ-S based on their total ex-perience. Data from these questionnaires and the six assessment formswith the actual client ratings were analyzed using both quantitative andqualitative procedures. The findings indicate that the VQ-S has clin-ical relevance and potential for implementation with adults with in-tellectual impairments. They also support the content validity of theVQ-S.

KEYWORDS. Assessment, clinical relevance, model of humanoccupation

INTRODUCTION

Swedish laws such as the Health and Medical Services Act (Halso-Sjukvardslagen [In Swedish] 1982), Social Services Act (Socialtjanstlagen[In Swedish], 2001), and the Act Concerning Support and Service for Per-sons with Certain Functional Impairments (Lag om Stod och Service tillVissa Funktionshindrade [In Swedish], 1993) emphasize clients’ rightsto influence their own interventions. According to the laws, clients, tothe extent that they are capable, should participate in decision-makingabout services. Moreover, all decisions about services shall be basedon respect for an individual client’s right to self-determination andprivacy. Occupational therapists must work in accordance with theselaws.

Consistent with the perspective of Swedish law, Kielhofner (2008)noted that it is vital for occupational therapists to understand a clients’wishes to participate in occupations in order to provide the right in-terventions, arguing that “the most indispensable part of assessment isto gain an understanding of a client’s volition” (Kielhofner, 2002, p.283). However, if the client has communicative and/or cognitive limi-tations, it can be difficult to use ordinary assessments, such as inter-views or self-reports to acquire knowledge about the volitional aspectsof the client (Kielhofner, 2008; Pollock & McColl, 1998; Wressle, Mar-cusson, & Henriksson, 2002). It was for this reason that the VolitionalQuestionnaire (VQ) was developed; it allows data on volition to begathered through observation (de las Heras, Geist, Kielhofner, & Li,2003).

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Alfredsson Agren and Kjellberg 165

THEORETICAL BASE OF THE VQ AND THE VQ-S

The theoretical base of the VQ is the Model of Human Occupation(MOHO) (Kielhofner, 2008), specifically the concept of volition. Volitionrefers to the motivation for occupations that is made up of thoughts andfeelings about one’s capacities for doing (personal causation), what isimportant to do (values), and what is pleasurable to do (interests). Volitionis an ongoing process in which people choose, experience, and reflect upontheir occupations. Because volition represents a dynamic interaction withthe environment, people may not be equally motivated in all environments.Thus, the VQ is ordinarily administered in different environments, andwhenever it is administered the salient characteristics of the environmentthat affect volition are noted.

The VQ (Table 1) consists of 14 items, representing observable behav-iors that reflect a client’s volition (i.e., they are observable expressions ofpersonal causation, values, and interests) (de las Heras, Geist, Kielhofner,& Li, 2003). Observation of a client takes 15–30 minutes, and it is recom-mended that clients should be observed on a number of occasions in differ-ent environments. After the observation, each item is rated with a 4-pointrating scale, which reflects the extent to which a client is spontaneouslymotivated versus needing support, structure, or encouragement to engagein the behaviors indicative of volition. The rater also observes and recordsthe qualities of the physical and social environment that influence volition.

TABLE 1. The 14 Items in the VolitionalQuestionnaire (VQ)

1. Shows curiosity2. Initiates actions/tasks3. Tries new things4. Shows pride5. Seeks challenges6. Seeks additional responsibilities7. Tries to correct mistakes/failures8. Tries to solve problems9. Shows preferences

10. Pursues an activity to completion/accomplishment11. Stays engaged12. Invests additional energy/emotion/attention13. Indicates goals14. Shows that an activity is special or significant

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PREVIOUS RESEARCH AND DEVELOPMENTOF THE VQ AND VQ-S

The VQ has been under development since the late 1980s. The firstversion of the assessment was studied by de las Heras (1993), who foundsupport for the content validity of the VQ. She also reported interrater reli-ability for the instrument. Following this Chern, Kielhofner, de las Heras,and Magalhaes (1996) found evidence using Rasch analysis that the itemsconverged to validly measure volition. They also found a ceiling effect,which led to a revision of the scoring system to more adequately mea-sure higher levels of volition. Revisions following these studies resultedin the third version in 1998 and version 4.0 in 2003 (de las Heras, Geist,Kielhofner, & Li, 2003). The most recent study by Li and Kielhofner(2004) found that the 14 items of the revised VQ (version 4.0) work welltogether to measure the underlying unidimensional concept of volitionwith less ceiling effects. In the first study in Sweden, Dahmen and duRietz Hakansson (2000) investigated occupational therapists’ perceptionof utility of the VQ. They concluded that the instrument was effectivein providing deeper knowledge about clients’ volition and suggested atranslation of the assessment into Swedish. Subsequently, the authors ofthe present study translated the VQ into Swedish, the VQ-S (AlfredssonAgren & Kjellberg, 2001), without major modifications from the Americanversions and made reference to both versions 3.0 (de las Heras, Geist, &Kielhofner, 1998) and 4.0 (de las Heras, Geist, Kielhofner, & Li, 2003) ofthe VQ.

STUDY AIM, DESIGN, AND METHODS

The purpose of this study was twofold: (a) to examine the utility of theVQ-S, explicitly its clinical relevance and ease of implementation and (b)to examine the content validity of the VQ-S. In examining utility, guide-lines were followed by Polit and Beck (2004), who recommend evaluatingan innovation (in this case using the VQ-S) by considering its philosoph-ical agreement with the context, its feasibility, its costs and benefits, andthe overall value of implementing it (Polit & Beck, 2004). This descriptivestudy used a survey method in which therapists completed three question-naires relevant to the study questions. They also made actual client ratingson the VQ-S.

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Alfredsson Agren and Kjellberg 167

Participant Selection and Ethical Procedures

The practitioners who are expected to use an assessment are best posi-tioned to evaluate the utility of an assessment (Benson & Clark, 1982; Polit& Beck, 2004; Wilson, 1989). Thus, a strategic sample of participants wasobtained based on two criteria. The first was that the occupational thera-pists should work with the primary population intended for the VQ-S, thatis, clients with cognitive and/or communicative disabilities. The secondwas that the participants should have theoretical knowledge of MOHO. Byasking potential participants to evaluate their knowledge of MOHO, thesecond criterion was operationalized.

Standard ethical procedures for the Swedish context were followed(Vetenskapsradet, 2003). The occupational therapists were informed, bothverbally and in writing, about the purpose of the study, their right towithdraw from the study at any time, and the guarantee of anonymity.Following this, their consent to take part in the study was obtained. Clientsgave their informed consent to each occupational therapist.

Instruments

Three questionnaires were constructed with both open and closed ques-tions concerning the utilization and content validity of the VQ-S. Thefirst questionnaire collected demographic data on the therapists includinginformation on the therapists’ previous knowledge of MOHO and theirexperience in using MOHO-based assessments.

The second questionnaire had two parts: (a) questions concerning clini-cal relevance and implementation of the VQ-S (e.g., how long it took, howeasy or difficult it was to implement, whether it provided deeper knowledgeabout the client) and (b) questions that captured therapists’ perception ofwhether the VQ-S adequately captured clients’ volition in order to assesscontent validity. The third questionnaire contained questions concerningthe administration manual and future use of the VQ-S in order to capturethe utility and further questions regarding the practitioners’ perception ofcontent validity.

Procedure

Sixteen occupational therapists attended the 4-hour introduction sessionin which they learned about the study and what was required for participa-tion; they also gave consent and completed the first questionnaire. During

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this session they were also given basic instruction in how to use the VQ-S since only 4 of them had previous exposure to the instrument. Due toworkload restrictions, 3 of the therapists who consented were unable tocomplete the study. During the following 6 months, 13 occupational thera-pists used the VQ-S a total of six times. Each therapist used the VQ-S withtwo different clients administering the VQ-S three times with each client.Following each administration of the VQ-S participants filled out the sec-ond questionnaire. The participants were asked to fill out the questionnairemultiple times, as it has been shown that perceptions regarding the utilityof instruments vary after they have been used a number of times (Streiner& Norman, 1995). The therapists then completed the third questionnaireonce after they had completed all the administrations of the VQ-S in orderto reflect their total experience of using the instrument.

Data Analysis

Responses on the three questionnaires, which summed up to a total of104, and actual client ratings on the VQ-S (n = 78) served as the data forthis study. The data were analyzed both qualitatively and quantitatively.Quantitative analysis was performed using Excel and yielded descriptivedata. The qualitative analysis was based on the answers to the open-endedquestions in the questionnaires, using content analysis (Berg, 2004; Grane-heim & Lundman, 2004). The text was read through several times, andthe manifest content (Graneheim & Lundman, 2004); that is, the visibleexamples in the text relating to the concepts of clinical relevance and im-plementation potential were analyzed. The organization of the manifestcontent was predetermined by these concepts, based on definitions in Politand Beck (2004).

RESULTS

Characteristics of the Occupational Therapy Participantsand the Clients They Assessed

Thirteen occupational therapists completed the study. They had workedwith the population intended for the instrument for a mean of 6.3 years.They all had theoretical knowledge of MOHO, gained through readingabout the model and/or using different MOHO-based assessments.

Of the 26 clients that were assessed with the VQ-S, 11 were female and15 male. Their mean age was 35.8 years old with a range of 21–62. All the

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Alfredsson Agren and Kjellberg 169

TABLE 2. Subjects Diagnosis (n = 26)

Diagnosis n

Mental retardation (severe to moderate) 12Mental retardation and cerebral palsy 8Mental retardation and autism 3Mental retardation and impaired vision 1Mental retardation and neurological disease 1Acquired brain injury 1

Total 26

clients had intellectual impairments, and 13 of them had various additionaldisabilities (Table 2).

Clinical Relevance

On 78% of the assessment occasions, the occupational therapists re-ported that, regardless of their prior knowledge about the client, using theVQ-S gave them deeper knowledge about the client. Therapists’ responsesto open-ended questions indicated that they gained information about boththe clients’ volition and the environmental factors that influenced volition.Therapists also reported finding out about additional information impor-tant to their therapy process. For instance, one therapist reported learningthat her client needed “more visual support to be able to perform tasksthan I thought.” Another therapist reflected: “I did not know that he was soGOOD at baking. He managed to pour . . . etc.” Therapists overwhelminglyreported that the VQ-S was useful in creating intervention plans (n = 12),in structuring the environment for the client (n = 12), and in cooperatingwith other staff working with the client in different settings (n = 11). Nineof the 13 therapists reported that results from the VQ-S shaped their treat-ment planning for the clients they assessed. Three therapists indicated thata lack of time was the reason they did not use the assessment results toinform their treatment plan.

All the occupational therapists stated that they could recommend theVQ-S to colleagues; 5 stated that they could recommend it to interdisci-plinary staff. Further, they all stated that they had other clients on theircaseload that would benefit from being assessed with the VQ-S. As onetherapist noted: “Many (clients) have problems expressing their volition.

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170 OCCUPATIONAL THERAPY IN HEALTH CARE

Staff members might fail to interpret the signs. It is good to have cleardocumentation that demonstrates this.”

Potential for Implementation

All occupational therapists reported that the MOHO theory underlyingthe VQ-S was consistent with the treatment philosophy and the regulationsgoverning their practice setting. The occupational therapists all agreedthat the VQ-S was a suitable tool for implementing the intentions of theAct Concerning Support and Service for Persons with Certain FunctionalImpairments (1993) in everyday practice. They agreed that volition wasclearly one of the concepts targeted in the Act.

The time required for administering the VQ (preparation, observation,and completion of the forms) was initially substantial, but diminished aftereach assessment by a total of 60 minutes (Table 3). The preparation timerequired was considered reasonable by the occupational therapists on 96%of the assessment occasions. On 91% of the assessment occasions, thetime for conducting the observation was considered reasonable. Finally,the time required to complete the forms was considered reasonable on only37% of the assessment occasions.

The occupational therapists were also asked for their perceptions of theirperformance during preparation, observation, and completing the forms.For assessment preparation, 8 therapists reported they did good or fairlygood on the first assessment occasion; and 11, on the last. During theobservation, 10 therapists reported themselves as good or fairly good onthe first occasion; and 11, the sixth occasion. When completing the forms,7 therapists reported they did good or fairly good on the first occasion and10 the last time. So, these perceptions changed in a positive direction acrossthe six assessment occasions, indicating the therapists’ growing confidencein their ability to administer the VQ-S.

With respect to the VQ-S manual 9 therapists rated the overall instruc-tions as good; and 4, as fairly good. The instructions regarding how touse the rating scale were found to be good by 4 occupational therapists,fairly good by 6, and not very good by 3. One of these three therapistscommented, “The instructions demand a lot of preparation. This makestheir use in daily life more difficult.”

Content Validity

All occupational therapists consistently stated across the 78 assessmentoccasions that the volitional aspects of the client are adequately assessed

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TABLE 4. The Number of Times (n) Each Item Has Been Assessed as “NotApplicable (N/A)” or With Any of the Other Ratingsa

Not Applicable Passive Hesitant Involved SpontaneousItems (N/A) (n) (n) (n) (n) (n)

Seeks challengesb 37 9 14 10 7Seeks additional responsibilitiesb 36 11 12 13 5Indicates goalsb 25 8 8 14 22Tries new things 24 4 10 28 12Invest additional energy/ 22 7 10 21 17

emotion/attentionb

Tries to solve problems 17 7 11 22 21Tries to correct mistakes/failures 16 9 9 17 27Shows pride 5 0 10 23 40Shows preferencesb 5 0 9 23 40Stays engaged 4 1 15 29 29Shows that an activity is special 3 1 8 20 45

or significantb

Pursues an activity to completion/ 2 3 23 28 22accomplishment

Shows curiosity 0 1 8 26 43Initiates actions/tasksb 0 1 15 31 30

aAll 78 assessments included.bOne drop-out per item i.e. the item has not been assessed with any of the ratings or N/A at one of the 78assessment occasions.

through the VQ-S. The items “Seeks challenges” and “Seeks additionalresponsibility” were most frequently rated by the therapists as “not ap-plicable (N/A),” meaning they judged that there was no opportunity toobserve whether clients would manifest these volitional behaviors. Theseitems were also the most frequently given lower ratings (Table 4). Theitems “Shows curiosity” and “Initiates actions/tasks” were never assessedas “N/A” on any of the 78 assessment occasions, and the lower ratingswere rarely used when assessing these items (Table 4).

DISCUSSION

In this study it was important that the research was conducted in the con-text of therapists’ actual practice in order to evaluate the utility and contentvalidity of the VQ-S from the practitioners perspective. This procedurealso increases the likelihood that a research innovation will be widely used(Sudsawad, 2005). The results of this study clearly support the conclusion

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Alfredsson Agren and Kjellberg 173

that the VQ-S provides occupational therapists with deeper knowledge ofthe client’s volition and that the knowledge is useful for treatment planning.Gaining deeper knowledge of the client is one criterion for good utility ac-cording to Law et al. (1994) and holds as a proof of clinical relevance(Polit & Beck, 2004). Use of the VQ-S and its underlying theory, MOHO,was deemed to be consistent with the philosophy and policies of treatmentsettings as well as with Swedish law (Act Concerning Support and Ser-vice for Persons with Certain Functional Impairments [in Swedish], 1993)that governs care of disabled persons, as has been noted in earlier studies(Haglund & Kjellberg, 1999).

The findings also support the conclusion that the VQ-S is reasonablyeasy to implement when used with people with cognitive and commu-nicative disabilities, especially adults with mental retardation, which wasthe primary diagnosis of clients seen by therapists participating in thisstudy. The occupational therapists were generally positive about the timerequirements for administering the VQ-S. However, on nearly 60% of theoccasions the occupational therapists indicated that it took a “long” or“too long” a time to complete the forms. It is notable, though, that 10occupational therapists considered their own performance during the lastassessment occasion as good or fairly good. A review of the VQ-S formscompleted by the participants during this study revealed that they wroteextensive qualitative comments on the forms. Anecdotal information fromclinical use of the instrument in other contexts suggest that the forms canbe completed in a much shorter time than the therapists in this study re-ported. No doubt, generating these qualitative comments was the mosttime-intensive aspect of completing the form. The VQ-S manual does notstipulate that the comments need to be as detailed as those provided by thetherapists in this study. It is not clear why the therapists invested so muchtime in creating these commentaries. This bears further scrutiny in futureresearch.

Nearly all the occupational therapists considered the VQ-S manual tohave adequate instructions, which is important for good utilization (Lawet al., 1994). However, opinions varied with respect to the specific instruc-tions on how to use the rating scale. One reason that therapists may havefound these instructions difficult is that they require the therapists to beactively involved with the client during observation in order to determinehow much support a client needs to show motivation. Such an approach toobservation is different from other observational assessments, which gen-erally call for the observer to be discreet and passive in order not to effectthe assessment. The most recent study of the VQ found that raters showeddifferences in their severity/leniency (Li & Kielhofner, 2004). Li and Kiel-

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hofner argued that the reason for this could be insufficient information inthe manual, and this study may further confirm their argument as threeoccupational therapists felt that the rating scale directions were not verygood. Differences in rater severity/leniency are not a threat to validity in theclinical application of assessments, but they can contribute measurementerror when data collected by different raters are aggregated (Kielhofner,2006). The reported discomfort of some therapists with the rating scaledoes not appear to diminish clinical utility in any way. However, in futureresearch and development of the VQ, this aspect of the instrument bearsmore consideration.

Therapists felt that the VQ-S adequately captured information on voli-tion, which supports the content validity of the instrument. The quantitativeanalysis in this study shows that, more than any other item, the items “Seekschallenges” and “Seeks additional responsibilities” are assessed more of-ten with “Not applicable (N/A).” When a rating “N/A” is frequently used, itmay indicate that the ability of that item to capture the underlying conceptshould be questioned (Wilson, 1989). The frequent use of “N/A” for thesetwo items could be related to therapists’ misunderstanding of what it meansfor there to be an opportunity for observing a behavior versus not seeingthe behavior, according to the manual. In the latter case, the absence of thebehavior merits a low rating. The “N/A” rating should only be used whenthere was absolutely no opportunity for the client to seek additional chal-lenges or responsibility. Theoretically, at least, this opportunity is alwayspresent, or can be made present by the therapists administering the VQ-S.Thus, it appears that the instructions in the manual should be modified tomore clearly indicate when to use a rating of “N/A.”

CONCLUSIONS

The VQ-S has clinical relevance and implementation potential for work-ing with adults with mental retardation as well as good content validity.The major challenges to utilization appear to be the time required for com-pleting the forms, the challenges of using the rating scale, and the use oftwo of the items “Seeks challenges” and “Seeks additional responsibil-ities” on the scale. It is possible that this can be dealt with by revisionand clarification of the manual. The Swedish version of the assessment isstill undergoing development and further revisions are needed to addressfindings in this study. Future research will need to address the reliabilityand construct validity of the VQ-S.

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Received: 07/20/2007Revised: 09/30/2007

Accepted: 09/30/2007

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