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Age and Ageing Advance Access originally published online on May 30, 2007
Age and Ageing 2007 36(5):544-548; doi:10.1093/ageing/afm052
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Copyright © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.

Cross-cultural validation of the London Handicap Scale and comparison of handicap perception between Chinese and UK populations

Raymond See Kit Lo1,, Timothy Chi Yui Kwok2, Joanna Oi Yue Cheng1, Hui Yang2, Hong Jiang Yuan3, Rowan Harwood4 and Jean Woo2

1 Department of Medicine and Geriatrics, Shatin Hospital, 33 A Kung Kok Street, Ma On Shan, New Territories, Hong Kong
2 Division of Geriatrics, Department of Medicine and Therapeutics, Chinese University of Hong Kong, 9/F, Prince of Wales Hospital, Shatin, N.T., Hong Kong
3 West China Health Promoting and Training Center on Aging, The 4th Hospital of Sichuan University, Chengdu, Sichuan, PRC 610041, China
4 Department of Health Care of the Elderly, A Floor East Block, University Hospital, Nottingham NG7 2UH, UK

Address correspondence to: R. S. K. Lo. Tel: (852) 26367500; Fax: (852) 26351037. Email: losk{at}ha.org.hk


   Abstract
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Objective: to validate the London Handicap Scale on populations from diverse cultures by comparing handicap perceptions in Mainland (Sichuan) Chinese, Hong Kong Chinese and UK subjects.

Method: utility ratings of 10 real life health scenarios were given by a group of healthy and disabled Sichuan Chinese subjects. The ratings were then correlated with published scale scores of HK and UK subjects on the same scenarios.

Setting: a university for older persons in Sichuan and the 4th Hospital of Sichuan University.

Subjects: two hundred and one Sichuan Chinese (mean age: 63.3 years) comprising of healthy (31.8%) and disabled individuals with stroke, fracture, cancer or other chronic conditions (69.2%) were recruited in the study.

Results: overall ratings for health scenarios were found to be highly correlated between Sichuan Chinese and UK subjects (r = 0.85; P < 0.0005), and between Sichuan and HK Chinese subjects (r = 0.98; P < 0.0005), with the exception of scenario J. Interesting differences in valuation were also observed between Sichuan subgroups in three scenarios. Self-perceived health status of the Sichuan Chinese can be accurately reflected by the severity of their handicap as measured by the London Handicap Scale LHS (r = –0.39, P = 0.000). For Sichuan Chinese, the economic domain of handicap was rated with poorer scores compared with the other domains.

Conclusion: the international notion of handicap, or limitation in participation, applies across different cultures and is also valid in mainland Chinese. UK, HK, and Sichuan subjects share similar perception on selected handicap scenarios. The London Handicap Scale is useful for health evaluation and outcome assessment for elderly of different cultures.

Keywords: aged, handicapped, London Handicap Scale, cross-cultural comparison, Chinese, elderly


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Handicap is a recognised outcome in the International Classification of Impairment, Disability, and Handicap (ICIDH) [1], for assessing the effects of chronic diseases and intervention. Handicap has been defined by the ICIDH as the disadvantage experienced by an individual resulting from impairment and disability, compared with what is normal for someone of the same age, sex, and background. It takes into account physical and psychological effects of a disease, the physical and social environment, and effects of health service interventions. Differentiating handicap from impairment and disability is important as measuring impairment and disability alone gives an incomplete picture of disease impact.

The London Handicap Scale (LHS) is a generic measure of handicap, and has been validated in populations in different states of health. It measures handicap based on six dimensions as classified in the ICIDH: mobility, occupation, physical independence, social integration, orientation and economic self-sufficiency [2]. It incorporates a six-point scale of disadvantage for each of the six dimensions. The six levels of handicap of the LHS on physical mobility are shown in Appendix 1, in the supplementary data on the journal website (http://www.ageing.oxfordjournals.org). In the recent International Classification of Functioning, Disability and Health (ICF) framework of bodily function, activity, and participation [3], handicap (or participation) is re-conceptualised as a component of health subject to influences of environmental factors, rather than as a consequence of disease as defined in the early ICIDH. LHS is still relevant in the ICF framework as it describes the effects of diseases and contextual factors that limit an individual's participation in life situations. It stands as a health status scale, measuring a relevant outcome of rehabilitation in its own right.

Measurement of handicap using the LHS in Western population and Hong Kong (HK) Chinese has been validated and published. The LHS has been tested in different healthy and patient populations including the elderly, with disabling chronic diseases such as stroke and arthritis in the West [4–13]. Research has also been done in HK, validating its use in HK Chinese. In a cross-cultural study in HK, close correlations were found between 164 HK Chinese and 224 United Kingdom (UK) subjects on the perception of severity of real life handicap scenarios [14]. This helps to confirm that the notion of handicap in rehabilitation applies across cultures. The Chinese translation of LHS is suitable as a measurement tool in evaluating outcomes of interventions aiming to reduce handicap. Longitudinal studies in HK Chinese stroke patients showed that measured handicap severity correlated closely with patients' quality of life scores [15]. The relationship between handicap and quality of life is also apparent when using measures other than the LHS [16]. A particular advantage with the LHS is that it is easy to use, less cumbersome and time-consuming than measures of quality of life in frail elderly subjects.

In mainland China as in other parts of the world, the population is rapidly ageing, with increasing prevalence of chronic diseases. There is a pressing need for a valid and easily applicable outcome measure for assessing the impact of diseases and rehabilitation. Any cultural differences regarding the perception of handicap or restriction in participation is important and also needs to be explored. The authors of this paper set out to evaluate a cross-cultural validation of the LHS in mainland Chinese, and to compare the perception of handicap between mainland China, HK, and UK subjects.


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Elderly subjects from a university for older persons in Sichuan, and disabled patients with a variety of chronic diseases from 4th Hospital of Sichuan University were recruited through convenience sampling for this study. Each subject was individually interviewed by a research assistant. The notion of handicap was introduced, and the full purpose of the study was explained. Informed consent was sought for all patients and those with cognitive impairment were excluded.

The Sichuan subjects were first asked to rate their perceived overall severity on 10 different handicap scenarios, using a 0 to 14 utility scale (0 representing no handicap at all, and 14 representing the worst handicap) as per the original methodology in the LHS manual [2]. These 10 handicap scenarios were all real life scenarios, experienced and described by UK subjects in previous studies using the LHS [4]. They were also the same scenarios used previously in a validation study with HK Chinese [14]. These scenarios were deliberately chosen to represent a wide range of severity and combination of problems. Each scenario described a state of health with different levels of handicap in the six dimensions. The 10 scenarios hence together provided different combinations of levels of handicap in different dimensions.

In rating the perceived overall severity of each of the 10 scenarios, the recruited subjects were invited to imagine that they themselves were living permanently in these states of health. Their ratings on these 10 scenarios were compared with expected UK scores, calculated from the published UK scale-weights, which reflected the preferences of the UK subjects. The ratings by the recruited subjects were also compared with the ratings by HK Chinese based on data collected from a previous validation study on 164 HK subjects. The utility ratings on the original 0–14 scale were all converted to a final 0–100 scale as the UK predicted scores were on a 0–100 scale, with 0 being the worse and 100 being the best [14]. Correlations were measured using Spearman's correlation coefficient.

Potential differences between the following subgroups of patients were analysed: age group, sex, education background, current severity of own handicap, and their self-perceived overall health status. Their own current handicap severity were self-rated by using the LHS. The final total score of the subjects' handicap were also transformed to a 0 to 100 scale. Self-perceived health status were rated on a categorical scale of 1 to 3, with 1 representing good, 2 representing fair, 3 representing poor. Significance of any subgroup differences were tested by one way ANOVA or unpaired t-tests. All statistics were calculated using SPSS for MS Windows release 8.0. [a]


   Results
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Two hundred and one Sichuan Chinese subjects were recruited. One hundred twenty eight subjects (64%) were elderly university students. The mean age of all subjects was 63.3 (median 64). Fifty percent were male. Sixty four subjects (31.8%) were healthy with no known illnesses at all. The remaining subjects were either disabled with stroke, fracture, cancer or other miscellaneous diseases. 25.4% of subjects received college or above education; 56.7% received either secondary or high school education; 17.9% received primary or no education at all.

As for the severity of the Sichuan subjects' own level of handicap as self-rated with the LHS, the mean scores on the six individual domains are shown in Table 1. The handicap domains with the best scores were the orientation and social domains. The handicap domain with the worst score was the economic domain. The overall total handicap score after incorporating all domains and transformed to a 0–100 scale was 70.2, SD 18.4 (100 = the best). As for the self- perceived health status, only 17.4% of subjects rated their health status as good, whereas 47.3% rated as fair, and 26.9% rated as poor. The mean score by the subjects was 2.1 and median 2, on the scale of 1 to 3 (1 = good, 2 = fair, and 3 = poor).


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  		Table 1. Descriptives of the 6 LHS domains (1 = least handicapped, 6 = most handicapped)

 
All subjects completed their utility ratings on the 10 different selected handicap scenarios. KS–Lillefor's tests revealed that scale ratings on the 10 scenarios were not normally distributed (P < 0.05). Nevertheless, non-parametric statistical methods showed that the overall correlation between Sichuan Chinese and UK ratings on the 10 different handicap scenarios was close (Spearman's rho = 0.85; P < 0.0005). The Sichuan Chinese ratings and the HK Chinese ratings were also very closely correlated (Spearman's rho = 0.98; P < 0.0005). Correlations between Sichuan and UK/HK scores on the 10 scenarios are shown in Figures 1 and 2 below. An exceptionally low correlation was found between Sichuan Chinese and the UK scores on scenario J, suggesting possible cultural differences despite overall congruence. For this scenario, the Sichuan Chinese rated it as rather unfavourable with mean score of only 21.3 out of 100, and HK Chinese also rated it unfavourably with score 17, though UK subjects scores were more favourable at 53.


Figure 1
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  		Figure 1. Correlations between Sichuan and UK scores on the 10 scenarios.

 


Figure 2
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  		Figure 2. Correlations between Sichuan and HK scores on the 10 scenarios.

 
Analysis of Sichuan Chinese subgroups preferences on different handicap scenarios also showed interesting differences. Those older than 75 rated scenario D more favourably than those younger than 75 (t = –4.46, P = 0.000). Male patients rated Scenario H more favourably than the female (t = 2.65, P < 0.01). Those who have poor self-perceived health status gave more favourable ratings for scenario G than those with fair perceived health status, who in turn rated the scenario more favourably than those with good perceived health status (F2,180 = 4.56, P < 0.05). For detailed descriptions of scenarios J, D, H and G, please refer to Appendix 2 in the supplementary data on the journal website http://www.ageing.oxfordjournals.org.easyaccess1.lib.cuhk.edu.hk/.

A statistically significant correlation was found between the patients' own handicap scores, and their self-perceived overall health status (r = –0.39; P = 0.000). Self-perceived health status of the Sichuan Chinese can be reflected by the severity of their handicap as measured by LHS. The poorer their handicap score, the worse were the health status that they perceived themselves to be in.


   Discussion
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This cross-cultural study proves convincingly that the international notion of handicap is applicable outside Western cultures. Similar to HK Chinese, mainland Chinese can also conceive of handicap as limited participation in daily activities when faced with disabling diseases. More remarkably, the mainland Chinese ratings on severity of different real-life handicap scenarios corresponded closely with that of UK subjects. This important finding validates handicap as a truly global construct, where preferences for or against certain handicap scenarios can indeed be similar in different nations. Not surprisingly, the ratings by the Mainland Chinese correlated even more closely to that by HK Chinese, given their common racial and cultural origins. Some argued that the concept of handicap or restriction in participation in one's social roles, may vary according to different norms, geographical context, culture and health systems [17]. However, our results have shown that handicap overall is a robust concept in different cultures and health settings, although variations can still be reflected.

A second important finding from this study is that the LHS is confirmed to be suitable for assessment of handicap in elderly mainland Chinese. Anecdotal feedback from the research assistants revealed that the LHS was easy to use and well understood by the elderly. Furthermore, the measured handicap scores can adequately reflect the self-perceived health status of the subjects, supporting the validity of the handicap scale and refutes claims that the LHS will be valid only in so far as the individual's perception of their handicap coincides with the views of the general public [18]. A cross-culturally valid and reliable handicap scale will be most useful in future studies and clinical trials, for assessing the impact of chronic disabling diseases as well as the effectiveness of interventions.

The description of the handicap profile experienced by the present sample of 201 healthy and disabled elderly has helped shed light on the needs of the mainland Chinese in rehabilitation. The domain of handicap that required more attention than others was the economic self-sufficiency domain as most of the present subjects came from rural villages and had very low income. In contrast, the social integration domain and the environmental orientation domain scored better. The relatively good social integration domain can indeed be attributed to the extended family structure which is still present in mainland China. Overall, the average handicap profile described by this group of patients seemed satisfactory, with a mean of 70 out of 100. It must be noted that our Sichuan findings may not generalise to populations from all parts of China as local culture and socioeconomic situations may lead to different handicap perceptions.

Despite overall congruence between the UK and Chinese subjects in perceiving the severity of different handicap scenarios, potential interesting cultural differences in one scenario can still be identified. As mentioned previously, scenario J highlights a situation where although mobility and physical independence are very limited, environmental orientation and social integration is still well preserved. Both mainland and HK Chinese subjects favoured this scenario much less than the UK subjects. This may imply that Chinese subjects tend to place more value on their mobility, physical independence, and ability to occupy themselves, than the other handicap domains. This is also supported by qualitative findings [19] that Chinese elderly stroke patients value self-reliance, autonomy and an internal locus of control as important quality of life determinants.

Significant differences were also found between age, gender and health status subgroups within the mainland Chinese subjects. Older subjects more favourably rated scenario D, where one is physically dependent with limited mobility and orientation, but has adequate finance and excellent social integration and occupation. It is possible that older persons are already experiencing and accustomed to the physical limitations as depicted in this scenario, so they do not consider it an unacceptable situation. As for gender differences, male subjects more favourably rated scenario H, where the person is physically independent, relatively mobile but needs help in all other domains. This may be due to traditional gender roles in China that require the males to be more ambulatory [20]. For those with lower self-rated health status, scenario G is rated more favourably. It is a scenario with little handicap in most domains but with a poor financial status. This reveals people's willingness to trade off monetary assets with good health [21], especially when they are already experiencing poorer health status and handicap.

Future study with larger samples would be needed to reveal more cultural differences and within-population subgroup differences in terms of rehabilitation needs. Identification of psychological and social determinants is important to enable multi-dimensional health assessments to be more comprehensive [22]. Whereas handicap depends much on physical, social and environmental factors, it is also worth further exploring the impact of overall illness perceptions [23] in influencing handicap perceptions.

In summary, the international notion of handicap, or limitation in participation, applies across different cultures and is also valid in mainland Chinese. Mainland Chinese share similar perceptions of the severity of handicap with UK and HK healthy and disabled elderly. The cross-culturally validated LHS is suitable for assessment of handicap in mainland China. Potential cross-cultural differences or differences between subgroups of Chinese population deserve further exploration.


   Key points
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  • The concept of handicap or limitation in participation is universally recognised.
  • Utility ratings of most handicap scenarios apply consistently across mainland Chinese, Hong Kong and UK populations.
  • Cultural and socio-economic differences in valuation of perceived handicap have been noted.
  • The LHS proved to be valid and applicable in the elderly population of mainland China.


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Version 11.5, SPSS Inc. 233 S. Wacker Dr, 11th Fl, Chicago, IL 60606.


   Source of funding
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The present research was not externally funded.


   Conflicts of interest
 
There are no competing conflicts of interest.


   Supplementary data
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Supplementary data for this article are available online at http://ageing.oxfordjournals.org.


   References
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  1. World Health Organization. International Classification of Impairments, Disabilities and Handicaps. A Manual of Classification Relating to the Consequences of Disease (1980) Geneva: WHO.
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  3. World Health Organisation. International Classification of Functioning, Disability and Health (ICF) (2001) Geneva: World Health Organization.
  4. Harwood RH, Rogers A, Dickinson E, Ebrahim S. Measuring handicap: the London Handicap Scale, a new outcome measure for chronic disease. Qual Health Care (1994) 3:11–6.[Abstract/Free Full Text]
  5. Harwood RH, Gompertz P, Ebrahim S. Handicap one year after a stroke: validity of a new scale. J Neurol Neurosurg Psychiatry (1994) 57:825–9.[Abstract/Free Full Text]
  6. Harwood RH, Carr AJ, Thompson PW, Ebrahim S. Handicap in inflammatory arthritis. Br J Rheumatol (1996) 35:891–7.[Abstract/Free Full Text]
  7. Harwood RH, Gompertz P, Pound P, Ebrahim S. Determinants of handicap 1 and 3 years after a stroke. Disabil Rehabil (1997) 19:205–11.[Web of Science][Medline]
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  12. Harwood RH, Ebrahim S. Measuring the outcomes of day hospital attendance: a comparison of the Barthel Index and London Handicap Scale. Clin Rehabil (2000) 14:527–31.[Abstract/Free Full Text]
  13. Foss AJ, Harwood RH, Osborn F, Gregson RM, Zaman A, Masud T. Falls and health status in elderly women following second eye cataract surgery: a randomised controlled trial. Age Ageing (2006) 35:66–71.[Abstract/Free Full Text]
  14. Lo RSK, Harwood R, Woo J, Yeung F, Ebrahim S. Cross-cultural validation of the London Handicap Scale in Hong Kong Chinese. Clin Rehabil (2001) 15:177–85.[Abstract/Free Full Text]
  15. Lo RSK, Kwok T, Wong E, Tang WK. Correlation between handicap and quality of life in 402 stroke patients. Qual Life Res. In: Proceedings from International Society for Quality of Life Conference (2004) Hong Kong.
  16. Patel MD, Tilling K, Lawrence E, Rudd AG, Wolfe CD, McKevitt C. Relationships between long-term stroke disability, handicap and health-related quality of life. Age Ageing (2006) 35:273–9.[Abstract/Free Full Text]
  17. Barbotte E, Guillemin F, Chau N, Lorhandicap Group. Prevalence of impairments, disabilities, handicaps and quality of life in the general population: a review of recent literature. Bull World Health Organ (2001) 79:1047–55.[Web of Science][Medline]
  18. Carr AJ, Thompson PW. Towards a measure of patient-perceived handicap in rheumatoid arthritis. Br J Rheumatol (1994) 33:378–82.[Abstract/Free Full Text]
  19. Lau A, McKenna K. Conceptualizing quality of life for elderly people with stroke. Disabil Rehabil (2001) 23:227–38.[CrossRef][Web of Science][Medline]
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  21. Jacobs RJ, Moleski RJ, Meyerhoff AS. Valuation of symptomatic hepatitis A in adults: estimates based on time trade-off and willingness-to-pay measurement. Pharmacoeconomics (2002) 20:739–47.[CrossRef][Web of Science][Medline]
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Received 22 December 2006; accepted in revised form 20 March 2007.


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