Development and COSMIN-based psychometric evaluation of the activities of daily living questionnaire for elderly iranian patients with chronic obstructive pulmonary disease (ADLEC): a sequential exploratory mixed-methods study using hybrid concept analysis
Year: 2026
Type: article
Abstract: Activities of daily living (ADL) are substantially compromised in elderly patients with chronic obstructive pulmonary disease (COPD) owing to exertional dyspnoea and fatigue. Generic instruments fail to capture disease-specific functional limitations, whereas existing disease-specific tools lack conceptual grounding and cultural sensitivity. The present study aimed to clarify the concept of ADL among elderly Iranian patients with COPD and to develop and psychometrically validate a culturally sensitive, disease-specific instrument—the Activities of Daily Living in Elderly COPD Patients (ADLEC) questionnaire—in accordance with the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) framework. A sequential exploratory mixed-methods design was utilised. In Phase 1, a hybrid concept analysis encompassing three stages (theoretical, fieldwork, and final analytical) was conducted with 15 elderly patients to delineate the conceptual attributes of ADL. In Phase 2, Waltz’s four-stage instrument development framework was employed to construct the items. Psychometric properties were evaluated across seven independent, non-overlapping samples (total N = 770), all recruited at a single national referral hospital for pulmonary diseases in Tehran, Iran. Exploratory factor analysis (EFA; n = 300) and confirmatory factor analysis (CFA; n = 250) were performed on independent samples. Reliability and agreement ( n = 30), construct validity via hypothesis testing ( n = 120), known-groups validity, longitudinal responsiveness ( n = 45), and gender-based measurement invariance ( N = 550) were systematically evaluated. The hybrid concept analysis identified three core attributes: the complexity and multifactorial nature of activity, dyspnoea and its modulators, and striving for independent living. The ADLEC was constructed as a 21-item questionnaire with a three-factor structure (Self-Care, Daily Physical Activity, and Energy Preservation & Social Participation) explaining 64.8% of the total variance. Confirmatory factor analysis indicated an adequate model fit (comparative fit index = 0.943, Tucker–Lewis index = 0.936, root mean square error of approximation = 0.069, standardised root mean square residual = 0.058). Latent-level construct validity was supported by the average variance extracted (0.60–0.76) and the heterotrait–monotrait ratio (< 0.85). The ADLEC correlated substantially with the COPD Assessment Test ( r = − 0.74), the St. George’s Respiratory Questionnaire ( r = − 0.71), and the six-minute walk test (r = + 0.62), and demonstrated large known-groups discrimination across Global Initiative for Chronic Obstructive Lung Disease severity stages (η² = 0.383). Overall scale reliability was excellent (Cronbach’s α = 0.938, McDonald’s ω = 0.93, intraclass correlation coefficient (2,1) = 0.920). The minimal detectable change at the 95% confidence level was 10.13 points and the minimal important change was 9.1 points. Longitudinal responsiveness was substantial (Cohen’s d = 0.69, standardised response mean = 0.80, area under the curve = 0.899). Strict measurement invariance across gender groups was confirmed (change in comparative fit index, ΔCFI = − 0.008). The 21-item ADLEC is a psychometrically sound, reliable, responsive, and culturally sensitive instrument. It is clinically feasible (mean completion time: 9.4 min) and may be used with a simple unweighted scoring approach to monitor functional status and evaluate pulmonary rehabilitation outcomes in elderly patients with COPD. Because all samples were drawn from a single referral hospital, multi-centre validation is warranted to confirm generalizability to other healthcare settings.
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $3,190
OpenAlex ID: W7222809246
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