POPS Syllabus

DESCRIPTION OF THE POPS
The Participation Objective, Participation Subjective (POPS) is a 26-item instrument, with two scoring systems, reflecting different perspectives – one the disability insider’s perspective of his/her participation in home and community activities, and the second reflecting societal/normative (“outsider”) valuations. The POPS emerged from a multi-focus research instrument, Living Life After Traumatic Brain Injury (or LLATBI; Gordon, Brown, et al, 1998). The LLATBI was developed in 1998, with most items drawn from existing instruments (see below). It was used in several studies implemented by the Research and Training Center on Community Integration of Individuals with TBI at Mount Sinai School of Medicine. In these studies, LLATBI data were gathered on 454 individuals with TBI living in the community and on 121 individuals with no disability. The participation items from the LLATBI were pared down to 26 to develop a more focused instrument: the POPS. These items then were analyzed in terms of differences between TBI subgroups, as well as in terms of reliability and validity (Brown, Dijkers, et al, 2004).

The POPS measure differs from typical community integration (CI) instruments in several ways: (1) It focuses solely on activities, not on non-activity indicators related to community functioning, e.g., income. (2) It generates two measures: the PO, comprising an objective measure of participation, and the PS, a subjective measure. (3) The PO gauges performance in terms of level of engagement, i.e., frequency or duration of engagement in activity in real life environments. This differs from some CI measures in that the focus is not placed on degree of impaired functioning. (4) Subjective assessment (the PS measure) incorporates the preferences of the interviewee by gauging the individual’s satisfaction with his/her level of engagement in each activity, weighted by his/her rating of the activity’s importance.

As is true of other CI measures, the POPS can be characterized as adopting societal assumptions with respect to the activities that are included. That is, each of its 26 items is an activity that is part of expected social role functioning for large segments of adults. In this respect, the POPS honors both societal expectations, in including activities valued by society in the PO component, as well as individual preferences, in its incorporation of individualized weighting of activities in the PS measure.

In the POPS, participation is defined as engagement in activities that are intrinsically social, or that are part of household or other occupational role functioning or that are recreational activities occurring in community settings. Each of the 26 activities listed in the POPS meets at least one of these criteria. Thus, for example, we excluded the potential activity “engages in exercise” because it is neither part of role functioning, nor is it necessarily a social or an out-of-home activity. The items in the POPS are not inclusive of all activities and roles that are indicators of participation in life activities, but instead represent significant and/or commonly occurring activities, organized in five subscales: Domestic Life (e.g., cleaning the house); Major Life Areas (e.g., working for pay); Transportation (e.g., driving or riding in a car); Interpersonal Interactions and Relationships (e.g., speaking with neighbors); and Community, Recreational and Civic Life (e.g., going to the movies). Creation of subscales was based on conceptual considerations and conformity with the International Classification of Functioning, Disability and Health3 (ICF) categorization of activities/participation, rather than statistical analyses of patterns in the data. Most of the content of the POPS was drawn from existing questionnaires, namely, the CHART (Whiteneck, Charlifue, et al, 1992), the CIQ (Willer, Rosenthal, et al, 1993), the Bigelow Quality of Life Questionnaire (Bigelow, McFarland & Olson, 1991; Bigelow, Gareau & Young, 1990), and the Community Re-entry Questionnaire (Whiteneck, Johnston, et al, 1992) (an unpublished measure of community involvement). Other items were developed specifically for the LLATBI/POPS, e.g., the transportation items.

In the POPS, each of the 26 activity items is addressed with two sets of questions. (Specific wording is noted in Appendix I.) Thus, in the Participation Objective (PO) aspect of the POPS, a stem question is asked, which varies somewhat with the category of activity. For the Domestic Life sub-scale activities, the stem question is couched in terms of the proportion of the activity for which the interviewee is responsible in a typical week. For Major Life Areas and Transportation, the stem question is couched in terms of the number of hours in a typical day or week the person engages in the activity. For the two remaining sub-scales, the stem question inquires about frequency of occurrence of the activity in a typical week or month. The interviewer, thus, suggests a time frame (e.g., a typical week) for the person to use in reviewing his/her activities (the appropriate time frame is coded behind the item; D, W or M). However, if it is easier for the person to report on “a typical day” or “a typical month”, instead of using the suggested time frame, he/she may do so. Frequency/duration data are recorded by the interviewer with a clear indication of the period used (e.g., 8 hours and per day are both recored), and are “translated” into a standard time period later in processing the PO data.

The POPS was developed using “typical week/month” as the frame within which the interviewee is asked to respond. For Sub-scales 2-5 (see Appendix I) the “past week/month” may be alternatively be adopted. Problems exist with each approach. The “typical day/week/month” framework, which we adopted, has the advantage of asking the interviewee to “even out” the “blips” in life activities that we all experience and (instead) report on what is “normal”, not on an atypical pattern that may have occurred in the past day/week/month. In other words, the researcher relies on the interviewee to reduce error variance relying on the insider’s knowledge of his/her life. The disadvantage is that, for some activities, “typical” may not occur or may be hard to define. Alternatively, using “ yesterday, or the past week/month” as the framework has the benefit of relying upon recentness of activity to optimize the reliability of the interviewee’s activity report. However, the past day/week/month may have been very atypical, so that the resulting data may “reliably” depict an aberrant activity pattern. Our preference is the “typical” approach.

The Participation Subjective (PS) portion of the POPS consists of a second set of questions asked with respect to each activity. Simplified, the questions are: What is the importance of this activity to your life satisfaction? And, Would you like to change your current level of engagement? This approach to subjective measurement was adapted from the work of Flanagan (Flanagan, 1978; Flanagan, 1982), who applied similar subjective stem questions in what later became the Quality of Life Scale (attributed to him by Burckhardt and colleagues; Burkhardt, Woods, et al, 1989).

GENERATING PO AND PS SCORES
In scoring the PO, first, all hour and frequency items are converted to a single base, which, depending on the item, is frequency or duration per day, week or month. Standardized (“z”) scores are then calculated by subtracting from each person’s raw score for each activity item the mean score for the item for the combined TBI and ND standardization samples (see Brown et al., 2004, for a description of these samples) and dividing by the standard deviation for the combined group. To control for outliers (due to errors in reporting participation or errors in data entry), the minimum and maximum z-scores are set at –3 and +3. (The percent of scores converted to +3 or -3 was under 4%, for all items for the standardization samples (Brown et al, 2004).) The z-score is then weighted by a factor that is the average of the mean importance rating of all persons in the TBI sample and the mean importance rating of ND individuals in the standardization sample for each item in question. This weighting ensures that all activities are not equated in scoring. For example, the score for working “should” be weighted more heavily than the score for going to the movies, to the extent that the people in the standardization samples on average view work as more important to their well-being than is movie going. The individual’s total PO score is calculated as the average of the weighted z-scores for the 26 individual items. Similarly, subtotal scores are calculated as the average weighted z-score for the items included in each subscale. (The POPS scoring algorithm, including group means and group importance scores for the standardization samples, is included as Appendix II.)

The POPS allows individuals to select the answer “Not Applicable” (NA) for certain items, e.g., care of children and yard work. Although it might be argued that by not doing these activities a person is less participatory in his/her community, and therefore a value of zero should be recorded, we have opted to consider NA a legitimate response. Along with “unknown” responses (participant doesn’t know, question was not asked, etc.), NA responses are considered missing values in the statistical analysis. All subscale scores and the total score, on PO and PS, can be calculated when information on a (small) number of items is missing.

Scoring of the PS is done by multiplying the individual’s importance score by his/her satisfaction score, where a person’s wanting less or more is scored as –1, and their being satisfied with current level (“same”) is scored as +1 (these values result from recoding the values recorded during the POPS interview: see Appendix I). Thus, for each item the person’s subjective score can range from +4, indicating a “most important” area of life that the person is engaging in at a satisfactory level, to –4, indicating an equally important area of life that the person wants to do either less of or more. The individual’s PS total score is simply a mean across the 26 activities.

This work was supported in part by a grant from the National Institute on Disability and Rehabilitation Research (NIDRR), Office of Special Education Services, U.S. Department of Education to Mount Sinai School of Medicine (H133B980013).

REFERENCES
Bigelow DA, Gareau MJ, Young DJ. A quality of life interview. Psychosoc Rehabil J. 1990;14(2):94-8.

Bigelow DA, McFarland BH, Olson MM. Quality of life of community mental health program clients: Validating a measure. Community Ment Health J. 1991;27(1):43-55.

Brown M, Dijkers MPJM, Gordon WA, Ashman T, Charatz H, Cheng Z. (2004). Participation Objective, Participation Subjective: A measure of participation combining outsider and insider perspectives. J Head Trauma Rehabil. 2004;19:459-481.

Burckhardt CS, Woods SL, Schultz AA, Ziebarth DM. Quality of life of adults with chronic illness: A psychometric study. Res Nurs Health. 1989;12(6):347-54.

Flanagan JC. A research approach to improving our quality of life. Am Psychologist. 1978; 33(2):138-47.

Flanagan JC. Measurement of quality of life: Current state of the art. Arch Phys Med Rehabil. 1982;63(2):56-9.

Gordon WA, Brown M, Hibbard M. Living life after TBI. New York: RTC on Community Integration of Individuals with TBI, Mount Sinai School of Medicine; 1998.

Whiteneck GG, Charlifue SW, Gerhart KA, Overholser JD, Richardson GN. Quantifying handicap: A new measure of long-term rehabilitation outcomes. Arch Phys Med Rehabil. 1992;73(6):519-26.

Whiteneck G, Johnston M, Gordon WA, Lehmkuhl D. Community re-entry questionnaire. unpublished; 1992.

Willer B, Rosenthal M, Kreutzer JS , Gordon WA, Rempel R. Assessment of community integration following rehabilitation for traumatic brain injury. J Head Trauma Rehabil. 1993;8:75-87.

World Health Organization. International classification of functioning, disability and health. Geneva: World Health Organization; 2001.

APPENDICES

Appendix I: Instrument Description
(Download as PDF: 36K or as a MS Word Document: 40K)

Appendix II: POPS SPSS Scoring Algorithm
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