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King's Health Questionnaire (KHQ)
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Supplemental: Spinal Cord Injury (SCI)
Short Description of Instrument
The King's Health Questionnaire (KHQ) measures the impact of lower urinary tract symptoms (e.g., urinary incontinence, overactive bladder) on health related quality of life. (Lui et al., 2010)
Scoring and Psychometric Properties
The KHQ is a 21-item scale with 9 domains: general health perceptions, incontinence impact, role limitations, physical limitations, social limitations, personal relationships, emotions, Sleep/Energy, and severity measures and an 11-item symptom severity score. (Hebbar et al., 2015)
The 21 questions are divided into eight categories: general health perception (1 item), incontinence impact (1 item), role limitations (2 items), physical limitations (2 items), social limitations (2 items), personal relationships (three items), emotions (three items), and sleep/energy (2 items).There are two independent scales: urinary symptoms and symptom severity. The scale has four options "not at all", "a little", "moderately" and "a lot"; or "never", "sometimes", "often" and "always". However, both the general health perception and personal relationships domains have five choices ("very good", "good", "fair", "bad" and "very bad") and ("not applicable", "not at all", "a little", "moderately" and "a lot"), respectively. (Karapolat et al., 2018)  In the KHQ, a minimum possible score of zero is assigned to the best health and a maximum possible score of 100 is assigned to the worst health. The 0-100 scale is used for each item and each subscale separately. (Kelleher et al., 1997; Kelleher, 1997; Karapolat et al., 2018)
Psychometric Properties
The KHQ has been extensively used in various diagnostic groups and general population. (Tate et al., 2020)
Reliability: The reliability of the KHQ has been demonstrated to be excellent for both internal consistency and test-retest reliability. (Kelleher et al., 1997) There have been at least 4 studies in SCI. (Tate et al., 2020) The test-retest reliability has been reported to be high (ICC: 0.69-0.94) as well as the internal consistency (alpha 0.68-0.93). (Tate et al., 2020; Karapolat et al., 2018)
Validity: The content validity has been established and the KHQ is considered a relevant and appropriate measure to assess the impact of an over active bladder in men and women. (Margolis et al., 2011) There have been two validation studies in SCI, of which one is a mixed sample (Turkish and Spanish versions). (Tate et al., 2020) Moderate to strong correlations between corresponding scales of the KHQ and the Qualiveen have been reported. (Karapolat et al., 2018) Moderate to weak correlations were reported between the KHQ with SF-36 scale. (Lui et al., 2010; Karapolat et al., 2018)
Responsiveness: Two SCI trials showed change of KHQ scores. (Hikita, et al., 2013; Pannek et al., 2019) One study showed no differences in scores (Akkoç et al., 2013), yet sensitivity to change has been demonstrated. (Kelleher et al., 2004)
Strengths/Weaknesses: The KHQ is a self-report measure and is easy to administer. The scoring is not straightforward and requires formulas.
Key References:
Kelleher CJ, Cardozo LD, Khullar V, Salvatore S. A new questionnaire to assess the quality of life of urinary incontinent women. Br J Obstet Gynaecol 1997;104:1374-1379.
Kelleher CJ. Quality of life. In: Cardozo L (ed.) Urogynecology. Churchill Livingstone, New York, 1997: 673-688.
Additional References:
Akkoç Y, ErsÖz M, Yildiz N, Erhan B, Alaca R, GÖk H, et al. Effects of different bladder management methods on the quality of life in patients with traumatic spinal cord injury. Spinal Cord 2013;51:226-231.
Hebbar S, Pandey H, Chawla A. Understanding King's Health Questionnaire (KHQ) in assessment of female urinary incontinence. Int J Res Med Sci 2015;3:531-538.
Hikita K, Honda M, Kawamoto B, Panagiota T, Inoue S, Hinata N, et al. Botulinum toxin type A injection for neurogenic detrusor overactivity: clinical outcome in J apanese patients. Int J Urol 2013;20:94-99.
Homma Y, Uemura S. Use of the short form of King's Health Questionnaire to measure quality of life in patients with an overactive bladder. BJU Int. 2004;93(7):1009-1013.
Karapolat H, Akkoç Y, EyigÖr S, TanigÖr G. Bladder-related quality of life in people with neurological disorders: reliability and validity of the Turkish version of the King's Health Questionnaire in people with spinal cord injury. Turk J Urol. 2018;44(5):411-417.
Kelleher CJ, Pleil AM, Reese PR, Burgess SM, Brodish PH. How much is enough and who says so? BJOG 2004;111:605-612.
Liu CW, Attar KH, Gall A, Shah J, Craggs M. The relationship between bladder management and health-related quality of life in patients with
spinal cord injury in the UK. Spinal Cord 2010;48:319-324.
Margolis MK, Vats V, Coyne KS, Kelleher C. Establishing the content validity of the King's Health Questionnaire in men and women with overactive bladder in the US. Patient. 2011;4(3):177-187.
Pannek J, Pannek-Rademacher S, Jus MS, Wollner J, Krebs J. Usefulness of classical homeopathy for the prophylaxis of recurrent urinary tract infections in individuals with chronic neurogenic lower urinary tract dysfunction. J Spinal Cord Med 2019;42:453-459.
PARQoL (2018). King's Health Questionnaire (KHQ). Accessed 01Oct2020 from
Romero-Culleres G, Sanchez-Raya J, Conejero-Sugranes J, Gonzalez-Viejo MA. Validation of the Spanish version of the King's health questionnaire for evaluating quality of life related to urinary incontinence in patients with spinal cord injury. Med Clin (Barc) 2011;137:491-494.
Tate DG, Wheeler T, Lane GI, Forchheimer M, Anderson KD, Biering-Sorensen F, Cameron AP, Santacruz BG, Jakeman LB, Kennelly MJ, Kirshblum S, Krassioukov A, Krogh K, Mulcahey MJ, Noonan VK, Rodriguez GM, Spungen AM, Tulsky D, Post MW. Recommendations for evaluation of neurogenic bladder and bowel dysfunction after spinal cord injury and/or disease. J Spinal Cord Med. 2020;43(2):141-164.
Document last updated November 2021