Psychometric assessment of the Life Satisfaction Questionnaire.docx

Psychometric assessment of the Life Satisfaction Questionnaire
(LSQ) and a
comparison of a randomised sample of Swedish women and
those su�ering from
breast cancer
Marianne Carlsson
1
, Elisabeth Hamrin
2
& Ragny Lindqvist
1
1Department of Public Health and Caring Sciences, Caring
Sciences Unit, Uppsala University, Sweden; 2Department of
Medicine and Care, Division of Nursing Science, University of
LinkoÈping, Sweden
Accepted in revised form 29 August 1998
Abstract. In a previous study, the Life Satisfaction
Questionnaire (LSQ) was developed especially for
women with breast cancer. The aim of the present
study was to assess the psychometric properties of the
LSQ in a randomized sample of Swedish women and
to compare the perceived quality of life with that of
women su�ering from breast cancer. Another aim was
to relate the result to educational background. A total
of 257 women aged 20±80, randomly selected from the

Swedish population register, answered the LSQ. The
result was compared with that from 362 women aged
27±78 su�ering from breast cancer. The construct
validity was calculated by a principal component
analysis, and the reliability by Cronbach a-coe�-
cients. It was concluded that the LSQ has acceptable
validity and reliability. The result also showed that the
women with breast cancer rated their perceived qual-
ity of life higher than women in general with respect to
the quality of personal relations and the quality of
daily activities, but lower for physical symptoms. In
the comparison with respect to educational back-
ground, women with university education rated their
quality of life higher than women with other types of
education. The testing of the LSQ will continue.
Key words: Breast cancer, Psychometric assessment, Quality of
life
Introduction
The term `quality of life' refers to a person's perceived
quality of her/his physical, psychological, social and
existential functioning [1]. Several instruments have
been developed to measure quality of life in di�erent
groups of people. Some measure quality of life in
general, e.g. the NHP (Nottingham Health Pro®le)
[2], the SIP (Sickness Impact Pro®le) [3], the Swed-
Qual [4], the MOS SF-36 (Medical Outcome Studies
Short Form) [5, 6], and the QLI (Quality of Life In-
dex) by Ferrans and Powers [7]. Others are more
speci®c, for instance, for cancer patients, the QLI
(Quality of Life Index) by Spitzer et al. [8], the FLIC
(Functional Living Index Cancer) [9], the CIPS
(Cancer Inventory of Problem Scale) [10], the

CARES (Cancer Rehabilitation Evaluation System)
[11], the FACT (Functional Assessment of Cancer
Therapy) [12], and the EORTC QLQ-C30 (European
Organisation for Research and Treatment in Cancer,
Quality of Life Questionnaire) [13].
A literature review by Carlsson and Hamrin [14]
showed that the diagnosis of breast cancer evokes
grief, anger and intense fear in women. But the ma-
jority do not experience long-term emotional distress.
Risk factors for psychological distress seemed to in-
clude many medical symptoms, little or no social
support from family and signi®cant others, little or
no hope of a recovery, a desire to give up, and great
concern about death. There were also some studies
where the outcome failed to prove any relationship
between breast cancer and psychosocial variables.
In a previous study, the LSQ-32 (Life Satisfaction
Questionnaire) was developed to assess the quality of
life of Swedish women with breast cancer [15]. The
instrument was developed by use of a principal
component analysis [16]. The results showed that
women with breast cancer estimated their quality of
life as quite positive, especially concerning the quality
of family relations and everyday life. Since there were
no data available for women in general, no certain
conclusion could be drawn. On the other hand, there
are studies of di�erent factors of importance for
women to normalize their life situation after a breast
cancer diagnosis.
According to Omne-PonteÂ n [17], living with a
spouse seemed to protect women from developing
psychosocial problems post surgery. And several

studies [18±20] have shown that social support is an
important factor for psychosocial adjustment and for
survival for women with breast cancer. Di�erent
sources of support have been studied (partner, family,
friends, relatives, and medical professionals), which
all turned out to be important in di�erent ways.
LaFortune Fredette [21] interviewed 14 women
who had lived at least 5 years after a diagnosis of
Quality of Life Research 8: 245±253, 1999.
Ó 1999 Kluwer Academic Publishers. Printed in the
Netherlands.
breast cancer. The women described how they tried to
adjust to the new situation by using multiple coping
strategies, with information seeking, work, spiritual-
ity, and family being predominant.
In a study by Hilton [22], 55 women with newly
diagnosed early stage breast cancer and their families
were interviewed in order to delineate how they coped
with the illness. The result showed that normalization
was an important process for these families, staying
normal and getting back to normal. One important
strategy, among others, was the reframing of nega-
tives to be more positive. One outcome of this was
satisfaction with the family state.
Collins et al. [23] investigated how the perception
of life satisfaction changed after a cancer diagnosis.
Cancer patients were asked 3 years after their diag-
nosis how their life values had changed. The results
showed that their attitude to the outside world and

the future had changed negatively, whereas their
evaluation of daily activities and personal relations
had changed in a positive direction.
The purpose of a study by Moch [24] was to ex-
plicate the concept of health within illness by de-
scribing women's experience of breast cancer. The
result showed that three di�erent themes were im-
portant, namely changing relatedness to others,
identifying meaning in the experience, and adding
new perspectives about life.
O'Connor et al. [25] interviewed 30 patients in or-
der to identify the process of personal search for
meaning conducted by patients who had been re-
cently diagnosed with cancer. The result showed that
many respondents re¯ected on their relationships
with other people and described them as ``closer'' as a
result of the cancer experience. Furthermore, some of
the respondents also described a general change in
attitude towards life as a result.
In a study by Mackenbach et al. [26] a comparison
was made between 11 countries in western Europe
(Denmark, England/Wales, Finland, France, Ger-
many, Italy, Netherlands, Norway, Spain, Sweden,
and Switzerland). Self-reported morbidity by level of
education, occupational class and/or level of income
was obtained for 1985 to 1992. Inequalities in health
were found in all countries. A relative index of in-
equality was calculated and the result showed that,
for women, the inequality of perceived health by
education was greatest in Sweden compared with the
other 11 countries.
In conclusion, there are studies indicating that a

serious diagnosis like cancer can make people change
their life values and life styles. Di�erent coping
strategies could be used in order to adjust to the
disease and try to normalize the life situation. Several
studies have also shown that social support and a
close relationship with others are important factors
for psychosocial adjustment. In addition, education
has been shown to be an important factor for the
perception of health.
The aims of the present study became twofold. One
aim was to assess the psychometric properties of the
LSQ in a randomized sample of Swedish women and
to compare the perceived quality of life with that of
women su�ering from breast cancer. Another aim
was to relate the perceived quality of life to educa-
tional background.
Research questions
1. What factors are identi®ed in the LSQ in a ran-
domised sample of Swedish women and what are
the internal consistency-coe�cients (Cronbach a)
of the factors?
2. Is the factor structure of the LSQ the same in the
randomised sample of Swedish women (RSW) as in
the sample of women su�ering from breast cancer
(BCW)?
3. Are there any di�erences in perceived quality of life
between the two samples, RSW and BCW?
4. Are there any di�erences in perceived quality of life
in Swedish women with di�erent levels of education?

Method
The instrument
The questionnaire originally consisted of 32 items
(version I) [15]; in the present version 34 items (ver-
sion II) were to be answered on a 7-point Likert-type
scale [27]. The questions are formulated in the fol-
lowing way. Example (1): ``How much have you been
troubled by tiredness during the last week?''. The
answer should be on a 7-point scale from (1) ``very
much'' to (7) ``not at all''. Example (2): ``How inter-
esting do you think your activities during the last
week have been?''. The answers could vary from (1)
``not interesting at all'' to (7) ``very interesting''.
In the ®rst test of the instrument (LSQ-32), 560
women with breast cancer in all stages were asked to
participate. All were registered in a regional cancer
register in south-eastern Sweden. They constituted all
women from two of the hospitals, and comprised
about 12% of all women in the regional cancer reg-
ister. They were judged by a chief physician not to be
terminally ill and to be able to answer the questions.
(The response rate was 74%, n = 414, but only 362
of the questionnaires were considered su�ciently
answered. Of those, however, 97 had left out single
items, which were calculated by use of mean substi-
tution. Most women (90%) were in an early stage of
the disease and only 10% had cancer in an advanced
stage. The women were between 27 and 76 years of
age (M = 60.7, SD = 10.23). Most of them (76%)
were married or lived with a partner; 24% lived
alone. Their educational background varied from
compulsory school 68%, secondary school 17%, and
university education 15%.

246
In the version of the questionnaire (LSQ-34) used
in the present study, the item ``necessity of activities''
was excluded due to comments from the respondents.
(The respondents meant that it was di�cult to tell the
necessity of an activity.) The following three items
were added: ``perceived overall health'', ``creativity in
activities'', and ``meaningfulness of activities''. In the
study by Carlsson and Hamrin [15], the women with
breast cancer also ®lled out the EORTC QLQ-C30
[13]. In the present study, the answers to the question
of perceived physical health in EORTC QLQ-C30
were used in order to make a comparison possible.
Subjects
Six hundred women aged 20±80 were randomly se-
lected from the Swedish population register (Semo
Group Info Data AB, 1995). The questionnaire,
LSQ-34, was mailed to the women and two reminders
were sent. The second reminder consisted only of
demographic data.
A total of 383 women returned the questionnaires.
Of those, only 111 answered the demographic ques-
tionnaire and 15 returned the questionnaire unan-
swered. Seventeen questionnaires were returned with
address unknown and 200 women did not answer at
all. This gives a response rate of 66%, of which 19%
only answered the demographic questionnaire. Two
hundred and ®fty-seven women answered the two
questionnaires completely.

The average age of these 257 women was 46.1 and
the standard deviation was 16.1 years. Most of them
(70%) were married or lived with a partner; 30%
lived alone. Their educational background varied
from compulsory school 28%, secondary school
38%, and university education 34%.
A comparison between the sample studied and
o�cial statistics [28] was made regarding age, country
of origin and level of education. This was done in
order to check how representative the ®nal sample
was. The comparison is shown in Table 1.
The work rate of the study sample was 76% and,
according to o�cial statistics, the comparable ®gure
is 74% [28].
The women in the present study were considered
representative with regard to age, country of origin,
and work rate. Concerning level of education, the
women in the present study had university education
to a somewhat higher extent.
Procedure
In order to investigate the construct validity of the
LSQ, the data from the 257 women was factor ana-
lysed, as a principal component analysis with varimax
rotation [16]. The analysis was interpreted in the
following way: for every item the highest factor
loading was identi®ed and the item was allocated to
that factor. Only factor loadings > 0:40 were re-
garded as signi®cant. Since there were some items
with high loadings in two factors (items 3, 9, and 34),

a second-order factor analysis was performed as well.
The result from that analysis was compared with the
result from that of women su�ering from breast
cancer [15]. Other statistical procedures were de-
scriptive statistics (mean values and standard devia-
tions), and, for comparisons, Student's one group t-
test, v2 analyses, and analyses of variance (ANOVA).
For post hoc tests, Fisher PLSD (p < 0:05), was used.
Cronbach alpha coe�cients [29] were used to test the
reliability. The StatView [30] computerized program
was used.
Results
The factor structure of the LSQ-34 in a randomized
sample of Swedish women (RSW)
The result of the factor analysis is shown in
Table 2.
The analysis gave six factors, which provided a
logical explanation of 60% of the variance. The fac-
tors were called: ``Quality of close friend relation
(Factor I)'', ``Physical symptoms (Factor II)'',
``Quality of everyday life (Factor III)'', ``Quality of
family relation (Factor IV)'', ``Socio-economic situ-
ation (Factor V)'', and ``Sickness impact (Factor-
VI)''. The internal consistency (reliability) coe�cients
are shown in Table 4.
The factor structure of the LSQ in the RSW-group
compared with the factor structure in the BCW-group
The factor analysis with LSQ-32 (the BCW-group)
also gave six factors explaining 64% of the variance,

Table 1. Comparison in percentage between the study
sample (n = 257) and Swedish o�cial statistics
Study
sample
O�cial
statistics
Age 18±24 8 11
25±44 37 34
45±64 32 30
65± 23 25
Country of origin Sweden 91 89
Other
countries
9 11
Level of education Compulsory
school
28 31
a
Secondary
school
38 44

University 34 22
a
Three percent were coded as missing value concerning
level of education.
247
Table 2. Factor loadings and communalities of the six factors
solution of the LSQ-34 for women in the RSW-group
(n = 257)
Item Factor I
Quality of
close friend
relation
Factor II
Physical
symptoms
Factor III
Quality of
everyday
life
Factor IV
Quality of
family

relation
Factor V
Socio-
economic
situation
Factor VI
Sickness
impact
Communality
1. Tiredness )0.105 0.235 0.006 0.131 0.381 0.512 0.491
2. Un®t )0.026 0.122 0.216 0.186 0.053 0.732 0.635
3. Di�culty sleeping 0.021 0.417 0.068 0.164 0.028 0.473 0.430
4. Loss of appetite )0.44 0.575 0.076 0.099 0.266 0.109 0.387
5. Diarrhoea )0.089 0.562 )0.087 0.159 )0.085 0.274 0.439
6. Constipation 0.187 0.508 0.117 )0.002 0.145 0.199 0.367
7. Dizziness 0.002 0.718 0.147 )0.042 0.124 0.156 0.678
8. Palpitation of the
heart
0.088 0.582 )0.036 0.261 )0.087 0.337 0.536
9. Di�culty breathing 0.239 0.407 )0.133 )0.042 )0.041 0.456
0.452
10. Muscular weakness 0.114 0.210 0.135 0.034 )0.56 0.751
0.643
11. Pain 0.148 0.198 0.205 )0.056 0.033 0.669 0.555
12. Nausea 0.076 0.725 0.034 )0.029 0.141 0.103 0.564
13. Perceived health 0.142 0.421 0.105 0.058 0.208 0.661 0.692

14. Satisfaction with
life situation
0.173 0.303 0.263 0.135 0.522 0.134 0.500
economic situation
)0.097 0.019 0.099 0.112 0.705 0.118 0.543
housing conditions
0.108 0.319 )0.020 0.124 0.541 )0.127 0.438
17. Level of activity )0.039 0.148 0.553 0.245 0.183 0.261
0.491
18. Activity: pleasant 0.281 0.056 0.664 0.156 0.303 0.232
0.708
19. Activity: interesting 0.236 )0.078 0.712 0.132 0.247 0.138
0.666
20. Activity: creative 0.104 0.031 0.712 )0.029 0.211 )0.053
0.566
21. Activity:
independent
0.146 0.144 0.696 0.167 )0.261 0.056 0.625
22. Activity: useful 0.092 0.014 0.772 0.225 )0.80 0.131 0.679
23. Activity:
meaningful
0.161 0.051 0.809 0.243 0.007 0.104 0.754
24. Family relation:

emotionally satisfying
0.188 0.171 0.141 0.795 0.150 )0.014 0.739
pleasant
0.279 0.014 0.099 0.815 0.166 0.096 0.789
meaningful
0.229 0.088 0.267 0.780 0.071 0.046 0.748
independent
0.260 0.089 0.300 0.580 )0.033 0.086 0.511
full of variations
0.231 0.018 0.194 0.708 0.143 0.167 0.640
29. Close friend relation:
emotionally satisfying
0.816 0.039 0.051 0.203 0.095 0.023 0.721
pleasant
0.808 0.009 0.143 0.252 0.065 0.070 0.746

how meaningful
0.847 0.083 0.146 0.235 )0.005 0.078 0.807
independent
0.715 0.094 0.266 0.141 )0.097 0.070 0.624
full of variations
0.732 0.020 0.188 0.212 0.043 0.169 0.647
34. Overall quality
of life
0.165 0.072 0.324 0.361 0.433 0.402 0.617
The items ®nally included in respective factors are in bold type.
248
and the reliability was calculated as the alpha-coe�-
cients for the di�erent factors [15]. (Table 4). The
eigenvalues and variance proportions for the six
factor-solutions after the varimax rotation, in the
BRC-group and the RSW-group, respectively, are
shown in Table 3. The factor ``Physical symptoms'',
explained 10% of the variance in the RSW-group and
16% in the BRC-group. The variance proportions of

the other factors were about equal.
All items except three (numbers 3, 9, and 10) loaded
in the same factor in the two analyses. Item number 3
(di�culty sleeping), number 9 (di�culty breathing),
and number 10 (muscular weakness) loaded in the
factor called ``Sickness impact'' in the RSW-group
and in the factor called ``Physical symptoms'' in the
BCW-group. In Table 5 the factor loadings, com-
munalities, eigenvalues, and variance proportions of
the second-order factor analysis for the RSW-group
is presented. The second-order factor analysis in the
RSW-group gave three factors that provided logical
explanations of 79% of the variance. The factors were
``Personal relation factor'' (originally factors `Quality
of family relation' and `Quality of close friend rela-
tion'), ``Physical factor'' (originally factors `Physical
symptoms', and `Sickness impact'), and ``Socio-eco-
nomic factor'' (originally factors `Quality of daily
activities', and `Socio-economic situation').
The second-order factor analysis for LSQ-32 in the
BCW-group gave three factors that provided logical
explanations of 81% of the variance. The factors
were ``Existential factor'' (orignally factors `Quality
of family relation', `Quality of daily activities', and
`Quality of close friend relation') ``Physical factor''
(originally factors `Physical symptoms', and `Sickness
impact') and ``Socio-economic factor'' (originally
factor `Socio-economic situation') [15].
The perceived quality of life in the RSW-group
compared with that in the BCW-group
A comparison showed that there were di�erences
between the women in the RSW-group and those in

the BCW-group in all six factors measuring di�erent
aspects of quality of life. (The maximum point for
each factor was recalculated to 100). In ®ve of the six
factors the women in the BCW-group scored higher,
whereas in one factor (Physical symptoms) the women
in the RSW-group scored higher. (see Table 6).
In Table 7, the BRC-group is divided into three
groups according to the stage of the disease. In the ®rst
group, 201 women in early stage of the disease were
included (stages CIS and I). In the second group, 123
women with breast cancer in stage II were included,
and in the last group, 38 women with breast cancer in
advanced stage were included (stages III och IV).
Perceived quality of life in women with di�erent
educational backgrounds
The comparison between women with di�erent edu-
cational backgrounds regarding perceived quality of
life showed signi®cant di�erences. Women with
university education scored higher in several of the
comparisons. See Tables 8 and 9.
For the women in the RSW-group, signi®cant
di�erences were found in four of the factors. In the
factor ``Quality of close friend relation'', women with
university education scored higher than those with
compulsory school education. In the factors ``Physi-
cal symptoms'' ``Sickness impact'', and ``Quality of
everyday life'' the women with university education
scored higher than those with compulsory school
education and those with secondary high school
education.

For the women in the BCW-group signi®cant dif-
ferences were found in four of the factors. In the
factors ``Quality of family relation'' and ``Quality of
everyday life'', the women with university education
scored higher than those with compulsory school
education. In the factors ``Physical symptoms'' and
``Socio-economic situation'' the women with univer-
sity education scored higher than those with com-
pulsory school education and those with secondary
high school education.
Table 3. Eigenvalues and variance proportions in the six factors
solution for the RSW-group (n = 257) and the BRC-
group (n = 362), respectively, after varimax rotation
Factor Group
RSW BRC
Eigenvalue Variance
proportion
Eigenvalue Variance
proportion
I Quality of close friend relation 3.8257 0.112 3.5068 0.110
II Physical symptoms 3.2724 0.100 5.2748 0.164
III Quality of everyday life 4.2601 0.125 3.4465 0.108
IV Quality of family relation 3.5772 0.105 3.6301 0.113
V Socio-economic situation 1.9959 0.059 2.1335 0.067
VI Sickness impact 3.4293 0.101 2.5773 0.081
Total variance 0.601 0.643
249

Analysis of missing cases
The response rate for RSW was 45%. But 66% of the
women answered a demographic questionnaire, and a
comparison between the women who answered both
the demographic questionnaire and the LSQ-34 and
the women who only answered the demographic
questionnaire showed some di�erences. The women
who did not answer the LSQ-34 were older
(M = 46.1, SD 16.28, for the women who answered
both questionnaires, and 50.9, SD = 17.60, for the
women who only answered the demographic ques-
tionnaire) (t = )2.675; df = 351, p = 0.0078). They
also di�ered signi®cantly regarding educational
background. Of the women who answered both
questionnaires, 28% had compulsory school, 39%
secondary school, and 33% university education;
among the women who only answered the demo-
graphic questionnaire, 43% had compulsory school,
35% secondary school, and 22% university education
(v2 � 10:318; df � 2; p � 0:0057�.
Discussion
In this study a new tool, the Life Satisfaction Ques-
tionnaire, LSQ, which was developed especially for
women with breast cancer, has been tried on a ran-
domised sample of Swedish women in order to
compare with those with breast cancer. We also
wanted to relate the result to educational back-
ground.

The response rate for RSW was rather low (45%),
which could be a problem for the external validity.
The factor structure of the LSQ-34 (RSW) turned out
to be almost the same as the factor structure for LSQ-
32 (BCW); both analyses provided a logical expla-
nation with six factors. But there were signi®cant
di�erences between the RSW-group and the BCW-
group regarding their perceived quality of life. The
women in the RSW-group estimated their quality of
life to be lower than the women in the BCW-group.
Finally, with both samples, the comparison regarding
educational background showed that women with
university education estimated their quality of life to
be higher than did the women with other educational
backgrounds.
Both ®rst-order factor analyses gave six logical
factors explaining 60% and 64%, respectively, of the
variance. All items except three loaded in the same
factor in the two analyses. The items ``di�culty
sleeping'', ``di�culty breathing'', ``muscular weak-
ness'' loaded in ``Sickness impact'' in the RSW-group
and in ``Physical symptoms'' in the BCW-group.
However, the factors ``Sickness impact'' and ``Physi-
cal symptoms'' turned out to be one factor in the
second-order factor analysis.
The a-coe�cients for the six factors were accept-
able for ®ve of the factors (0.75±0.92). The a-coe�-
cients for the sixth factor (``Socio-economic
situation'') were 0.62 and 0.69, respectively. This
factor consisted of only four items, which might ex-
plain the low value. Since the two factor analyses
gave the same factors and the a-coe�cients were
satisfactory, the construct validity as well as the re-
liability of the LSQ for the two samples of women

could be considered acceptable.
When the ®rst-order factors were considered, all
di�erences but one indicated that the women in the
RSW-group estimated their quality of life to be lower
compared with the women in the BCW-group. The
Table 4. Cronbach a-coe�cients for the six factors of the
LSQ-34 (RSW) and the LSQ-32 (BCW), respectively
Factor RSW (n =257) BCW (n = 362)
a a
Quality of close
friend relation
0.90 0.86
Physical symptoms 0.75 0.90
Quality of daily
activities
0.92 0.83
Quality of family
relation
0.87 0.88
Satisfaction with
socio-economic
conditions

0.62 0.69
Sickness impact 0.85 0.83
Table 5. Factor loadings, communalities, eigenvalues, and
variance proportions of the second-order factor analysis for
LSQ-34 (RSW) (n = 257)
Original factor Personal relations Physical function Daily living
Communality
Quality of close friend relation 0.924 0.130 0.068 0.875
Physical symptoms 0.086 0.904 0.121 0.839
Quality of everyday life 0.447 0.076 0.682 0.670
Quality of family relation 0.684 0.123 0.476 0.710
Socio-economic situation 0.050 0.327 0.841 0.817
Sickness impact 0.148 0.842 0.240 0.789
Eigenvalue/magnitude 1.5532 1.7007 1.4758
Variance proportion 0.259 0.283 0.246 0.784
a
a
cumulative variance proportion.
250
women in the RSW-group experienced fewer physical
symptoms than the women in the BCW-group. On
the other hand, however, the women in the RSW-
group experienced more sickness impact than the

women in the BCW-group. The study by Hilton [22]
suggested that normalization, and di�erent ways to
keep normal and to return to normal, was important
for women with breast cancer. One way to do that
was to reframe negative cognitions into more positive
ones. The participants in that study were women with
newly diagnosed early stage breast cancer, which
meant that they were not terminally ill. In the BCW-
group, 90% had breast cancer in an early stage and
less advanced stage of the disease and 10% in an
advanced stage [15]. That could be one explanation
for why the women in the BCW-group estimated
their quality of life to be better than the women in the
RSW-group; they behaved like the women in the
study by Hilton [22] who tried to normalize and,
through that process, reframed negative cognitions.
The women in the BRC-group who su�ered from
breast cancer in an advanced stage di�ered signi®-
Table 6. Comparisons according to means between RSW (n =
257) and BCW (n = 362) regarding di�erent aspects of
perceived quality of life. (The maximum point for each factor is
recalculated to 100). Statistics: Student's one-group t-test
Factor RSW BCW t-values p-values
n = 257 n = 362
Mean (SD) Mean (SD)
Quality of family relation 77.68 (15.07) 83.65 (13.75) )8.27
0.0001
Quality of close friend relation 74.31 (14.49) 82.93 (14.80)
)11.082 0.0001
Physical symptoms 89.37 (11.06) 82.09 (13.17) 10.517 0.0001
Sickness impact 70.36 (16.98) 76.16 (15.55) )7.101 0.0001

Quality of everyday life 69.14 (14.93) 83.65 (13.75) )20.191
0.0001
Socio-economic situation 75.04 (14.29) 77.07 (12.77) )3.027
0.0026
Table 7. Comparisons between RSW (n = 257) and BCW,
divided into three categories according to the stage of the
disease, regarding di�erent aspects of perceived quality of life.
The maximum point for each factor is recalculated to 100.
Statistics: ANOVA
Factor RSW (n = 257)
Mean (SD)
BCW early
stage (n = 201)
Mean (SD)
p-value
BCW less
advanced stage
(n = 123)
Mean (SD)
p-value
BCW advanced
stage (n = 38)
Mean (SD)
p-value
Quality of family relation 77.68 (15.07) 92.35 (15.23) 92.45
(11.91) 92.04 (10.46)

p = 0.0001 p = 0.0001 p = 0.0001
Quality of close friend relation 74.31 (14.49) 83.80 (15.38)
82.70 (13.19) 79.11 (16.29)
p = 0.0001 p = 0.0001 n.s.
Physical symptoms 89.37 (11.06) 80.78 (13.26) 83.50 (12.61)
83.09 (13.95)
p = 0.0001 p = 0.0001 p = 0.0078
Sickness impact 70.36 (16.98) 76.57 (15.16) 76.00 (15.45)
74.56 (18.07)
p = 0.0001 p = 0.0001 n.s.
Quality of everyday life 69.14 (14.93) 82.46 (13.60) 85.44
(13.26) 84.21 (15.66)
p = 0.0001 p = 0.0001 p = 0.0001
Socio-economic situation 75.04 (14.29) 77.16 (12.31) 77.50
(13.37) 75.38 (13.37)
p = 0.0154 p = 0.0479 n.s.
Table 8. Perceived quality of life in women in the RSW-group
(n = 257) with di�erent levels of education. Statistics:
ANOVA
Level of education Quality of
family relation
Quality of close
friend relation
Physical

symptoms
Sickness
impact
Quality of
everyday life
Socio-economic
situation
M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)
Compulsory school 75.89 (16.4) 70.77 (15.9) 88.37 (10.6) 68.38
(16.1) 65.17 (14.3) 75.53 (15.2)
Secondary school 77.43 (14.9) 74.23 (14.5) 87.88 (12.3) 67.06
(17.6) 66.53 (14.4) 74.49 (13.7)
University 79.72 (14.1) 77.30 (12.7) 91.84 (9.6) 75.70 (15.9)
75.34 (14.3) 76.90 (13.7)
F-value 1.0924 4.0564 3.3968 6.916 12.5189 1.2027
p-value 0.337 0.0184 0.035 0.0012 0.0001 0.3021
251
cantly from the RSW-group in three factors; they
su�ered from more physical symptoms and experi-
enced higher quality in their everyday life and in the
relationships with their families.
Other studies have shown that valuing relation-

ships with other people and daily activities more [23±
25] could be coping strategies that might be possible
explanations for the di�erences between the women
in the RSW-group and the women in the BCW-
group. That the women with cancer (BCW) estimated
their quality of life regarding the quality of family
relationships and of close friend relationships higher
than women did in general supports the conclusions
from other studies [17±20] that social support is an
important factor for the psychosocial adjustment of
women with breast cancer.
The second-order factor analyses for the RSW-
group and the BCW-group did not turn out exactly
the same. In both analyses the most logical solution
contained three factors. The factor, ``Physical fac-
tor''. was identical, but the other two di�ered. The
®rst-order factor, ``Quality of daily activities'', loaded
in the ``Socio-economic factor'' for women in the
RSW-group and in the ``Existential factor'' for
women in the BCW-group. This is an interesting
di�erence that could be explained with the help of the
results from Moch [24] and O'Connor et al. [25],
whose results showed that in the personal search for
meaning in the cancer experience, new perspectives
about life could be added and general changes in
attitude towards life could develop. Possible expla-
nations could be that women with cancer re-evaluate
ordinary daily activities and that they perform
acitivities they do not like to a lesser extent than
before the cancer disease.
The result of the present study was in agreement
with the results from the study by Mackenbach et al.
[26]. Women with university education estimated
their quality of life to be higher than women with

compulsory school education and secondary educa-
tion. This was true for the women in the RSW-group
as well for those in the BCW-group. Why women
with university education estimated their quality of
life to be higher than other women is interesting, but
in the present study, it is not possible to speculate
about the reasons for that.
In conclusion, the result of the present study shows
that the LSQ has acceptable reliability and validity.
The factor structure of the LSQ-34 turned out to be
almost the same as the factor structure for LSQ-32,
both analyses providing a logical explanation with six
factors. It was also concluded that it is possible to
experience good quality of life in spite of having
breast cancer. The women in the BCW-group even
estimated their quality of life to be higher than the
women in the RSW-group, possibly because the
cancer diagnosis made them re-evaluate their life
situation and reframe negative cognitions in order to
normalize the experience. University education
turned out to be positively correlated with high values
of perceived quality of life. The testing of the LSQ
will continue.
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Quality of close
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Physical
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Sickness
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Quality of
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Socio-economic
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252
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Address for correspondence: Marianne Carlsson, Ph. D,
Associate Professor, Department of Public Health and
Caring Sciences, Caring Sciences Unit, Uppsala University,
Sweden
Fax: 46 18 471 34 90
253
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confidence level C and sample size N. C= 0.95, N=26

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