Validation of the Thai version of the World Health Organization’s Quality of Life Scale (WHOQOL-BREF-THAI) among Thai nursing students in northeast Thailand: A multi-centre study

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However, there is a lack of existing research on its comprehensive psychometric properties, specifically when used with nursing students. This study examined the WHOQOL-BREF’s unique psychometric features with Thai nursing students in northeast Thailand. Methods In this cross-sectional study, Thai nursing students were recruited using multi-stage simple random sampling from universities located in the northeast of Thailand. The data was collected via self-assessment questionnaires, and the 3,570 participants were then randomly split into two subsamples (group 1, n=2,000, and group 2, n=1,570). After reducing the number of items using statistical methods, an exploratory factor analysis (EFA) was carried out on group 1 to explore the factor structure of the WHOQOL-BREF-THAI. Finally, group 2 was used in a confirmatory factor analysis (CFA) to validate the EFA’s modified structure along with an assessment of the construct validity of the WHOQOL-BREF-THAI. Results Principal component analysis on a random subsample supported a four-factor model with 24 items, originally suggested for factorial construct validity; these 24 items were distributed across the original four domain. The domain structure for the purpose showed a good fit in the CFA on the other subsample. Internal reliability was satisfactory (Cronbach’s alpha was greater than 0.70) for both the total scale and subscales. In terms of convergent validity, average variance extracted (AVE) revealed that all WHOQOL-BREF-THAI subscales achieved convergence, with AVE values ranging from 0.50 to 0.69. Conclusion These results reveal that the WHOQOL-BREF-THAI is a valid and reliable tool which health care providers can utilize to measure QOL among Thai nursing students. Therefore, the WHOQOL-BREF can serve as an essential tool for researching the factors influencing nursing students’ QOL, with implications for nursing education. 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F1000Research 2025, 14 :241 ( https://doi.org/10.12688/f1000research.161251.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Validation of the Thai version of the World Health Organization’s Quality of Life Scale (WHOQOL-BREF-THAI) among Thai nursing students in northeast Thailand: A multi-centre study [version 1; peer review: 1 approved with reservations] Ueamporn Summart https://orcid.org/0000-0001-9557-2199 1 , Monthida Sangruangake 2 , Jumrusluk Charoensaen 3 , Wiraporn Suebsoontorn 4 , Metha Songthamwat https://orcid.org/0000-0002-5694-8138 5 Ueamporn Summart https://orcid.org/0000-0001-9557-2199 1 , Monthida Sangruangake 2 , [...] Jumrusluk Charoensaen 3 , Wiraporn Suebsoontorn 4 , Metha Songthamwat https://orcid.org/0000-0002-5694-8138 5 PUBLISHED 27 Feb 2025 Author details Author details 1 Faculty of Nursing, Roi Et Rajabhat University, Kho Kaew Subdistrict, Selaphum District, Roi Et, 45120, Thailand 2 Faculty of Nursing, Udon Thani Rajabhat University, Udon Thani, Udon Thani, Thailand 3 Faculty of Nursing, Roi Et Rajabhat University, Ko Kaeo Subdistrict, Selaphum District, Roi Et, Thailand 4 Faculty of Nursing, Nakhon Ratchasima Rajabhat University, Nakhon Ratchasima, Nakhon Ratchasima, Thailand 5 Department of Obstetric and Gynaecology, Udon Thani Hospital, Udon Thani, Udon Thani, Thailand Ueamporn Summart Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Methodology, Project Administration, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Monthida Sangruangake Roles: Conceptualization, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Jumrusluk Charoensaen Roles: Conceptualization, Methodology, Writing – Original Draft Preparation Wiraporn Suebsoontorn Roles: Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Metha Songthamwat Roles: Data Curation, Formal Analysis, Investigation, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Social Psychology gateway. Abstract Background The Thai version of the World Health Organization Quality of Life Scale (WHOQOL-BREF-THAI) has been verified among a variety of populations. However, there is a lack of existing research on its comprehensive psychometric properties, specifically when used with nursing students. This study examined the WHOQOL-BREF’s unique psychometric features with Thai nursing students in northeast Thailand. Methods In this cross-sectional study, Thai nursing students were recruited using multi-stage simple random sampling from universities located in the northeast of Thailand. The data was collected via self-assessment questionnaires, and the 3,570 participants were then randomly split into two subsamples (group 1, n=2,000, and group 2, n=1,570). After reducing the number of items using statistical methods, an exploratory factor analysis (EFA) was carried out on group 1 to explore the factor structure of the WHOQOL-BREF-THAI. Finally, group 2 was used in a confirmatory factor analysis (CFA) to validate the EFA’s modified structure along with an assessment of the construct validity of the WHOQOL-BREF-THAI. Results Principal component analysis on a random subsample supported a four-factor model with 24 items, originally suggested for factorial construct validity; these 24 items were distributed across the original four domain. The domain structure for the purpose showed a good fit in the CFA on the other subsample. Internal reliability was satisfactory (Cronbach’s alpha was greater than 0.70) for both the total scale and subscales. In terms of convergent validity, average variance extracted (AVE) revealed that all WHOQOL-BREF-THAI subscales achieved convergence, with AVE values ranging from 0.50 to 0.69. Conclusion These results reveal that the WHOQOL-BREF-THAI is a valid and reliable tool which health care providers can utilize to measure QOL among Thai nursing students. Therefore, the WHOQOL-BREF can serve as an essential tool for researching the factors influencing nursing students’ QOL, with implications for nursing education. READ ALL READ LESS Keywords Quality of life, Nursing, Southeast Asian people, WHOQOL-BREF, Confirmatory factor analysis. Corresponding Author(s) Ueamporn Summart ( [email protected] ) Monthida Sangruangake ( [email protected] ) Close Corresponding authors: Ueamporn Summart, Monthida Sangruangake Competing interests: No competing interests were disclosed. Grant information: This research project was supported by The Fundamental Fund: FF 2024, Roi Et Rajabhat University (Grant Number 203446). We confirm that the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Summart U et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Summart U, Sangruangake M, Charoensaen J et al. Validation of the Thai version of the World Health Organization’s Quality of Life Scale (WHOQOL-BREF-THAI) among Thai nursing students in northeast Thailand: A multi-centre study [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :241 ( https://doi.org/10.12688/f1000research.161251.1 ) First published: 27 Feb 2025, 14 :241 ( https://doi.org/10.12688/f1000research.161251.1 ) Latest published: 22 Jul 2025, 14 :241 ( https://doi.org/10.12688/f1000research.161251.3 )  There is a newer version of this article available. Suppress this message for one day. Introduction The concept of quality of life (QOL) 1 refers to a person’s perception of their current condition, considering existing cultural norms and values. This judgment includes a person’s objectives, expectations, standards, and concerns . 2 QOL can be defined as a comprehensive, complicated notion that includes autonomy, individual and subjective perceptions, and the integration of biopsychosocial components. 3 University life is one of the most difficult yet exciting phases of any person’s life. Every student must deal with a wide variety of complex situations that prepare them for their future career and life. 4 Many factors impact university students’ QOL, such as psychological issues, social relationships, and self-evaluation. These factors may have a major effect on the daily lives of students, their academic performance, and their overall behaviour. 5 Nursing students are a group of people whose QOL is being challenged. While undergoing their training, they are exposed to many stressful and difficult situations, such as assisting mothers in labour, coping with traumatic events, overcoming problems and restrictions, and ensuring that patients are able to die with dignity. 6 Moreover, prior studies have reported that higher stress perceptions, arising from patient care, the clinical setting, and interactions with faculty, peers, and staff, all predicted a negative QOL. 7 In terms of these highly stressful situations, a poor QOL may have an impact on nursing students’ learning processes or even cause them to drop out, resulting in a lower quality and standard of graduate nurses. 8 As a result, maintaining good QOL among nursing students is essential so that nursing instructors can help shape students into effective registered nurses. QOL evaluation is critical for determining whether nursing students have excellent well-being levels as they progress through the learning process. Therefore, to assess the effectiveness of an intervention in increasing a person’s QOL, it is critical to use a validated test that measures all elements of life. While most QOL measures commonly evaluate how physical and mental health issues affect daily living, 9 the World Health Organization Quality of Life Instrument-Abbreviated Version (WHOQOL-BREF), one of the most widely used questionnaires, goes beyond evaluating medical outcomes to incorporate social and environmental aspects. 1 In a cross-sectional study of preclinical medical students in Saudi Arabia using the WHOQOL-BREF, strong academic achievement was positively associated with QOL, particularly in the physical health, psychological health, social relationships, and environment domains. 10 Similarly, it has been found that the academic success motivation and QOL domains of nursing students have relationships, especially in the psychological health domain. 11 The WHOQO-BREF, a shortened version of the WHOQOL-100, was developed for simplified administration and was evaluated in 23 countries, including Thailand. It comprises 24 items designed to examine QOL perceptions in four domains: physical health, psychological health, social relationships, and environment, as well as two items on overall QOL and general health. 12 Globally, many studies employing various target demographic samples (both general population and those with a variety of diseases) have indicated that that the WHOQOL-BREF questionnaire has excellent psychometric properties. 13 – 25 This scale has been confirmed as a four-factor structure according to many validation studies. 13 , 23 , 26 However, inconsistency in the factorial structure via confirmatory factor analysis (CFA) still exists across different settings. Prior validation research, however, demonstrated that a two-factor model was the optimum model for the modified WHOQOL-BREF test in a large sample of teenagers in Nigeria. 27 Another study in Vietnam used alternative models with only three factors in young adults. 28 Moreover, previous research using the WHOQOL-BREF among samples of Portuguese-speaking people from three different countries on three different continents discovered distinct WHOQOL-BREF configural structures among these samples. These results suggest that the cultural context can influence the WHOQOL-BREF QOL assessment. 17 In addition, another study in Thailand found that an extended five-factor scale, in the medical care domain, could be utilized by health care practitioners to accurately assess the demands of women who had experienced intimate partner violence. 29 To date, the psychometric qualities of the Thai version of the WHOQOL-BREF have been studied in a broad range of populations, such as patients with HIV, and college students in Thailand. 13 , 29 , 30 However, comprehensive documentation of the psychometric properties, including factor structure (particularly among nursing students), in this setting is completely lacking in the literature, except for use of this tool for QOL assessment. One recent study revealed that the overall QOL of 273 nursing students was high, and the reliability of this instrument was 0.95. 8 Since a comprehensive review of the instrument’s psychometric properties remains lacking, these findings may not be valid for nursing students. In addition, previous evidence confirmed that, before this tool can be used with these students, its psychometric properties must first be validated for this population, especially since prior research found significant issues when the questionnaire was utilized with younger adult samples. 6 , 31 , 32 In nursing education, it is critical to measure QOL to optimize training, as stress and burnout are significant factors influencing drop-out rates. 7 , 32 Nursing students’ QOL is also likely to have an impact on their future clinical competence. Consequently, resolving this issue requires the application of a tool designed specifically for assessing their QOL. Given these concerns, the goal of this research was to assess the psychometric properties of the WHOQOL-BREF-THAI when applied to Thai nursing students. Methods Research design This cross-sectional study was conducted using the dataset derived from a larger multi-centre study a project entitled “The prevalence and risk factors of non-communicable diseases (NCDs) among undergraduate nursing students in Northeast Thailand”. The recruitment of student participants was carried out by research partners from participating universities, beginning on various dates between June 2024 to September 2024. Sample and sampling technique The target population of this study comprised Thai nursing students nationwide, and sampling was undertaken using a multistage sampling technique. In the first stage, 15 nursing institutions were chosen using a simple random sampling technique from 23 nursing institutions in northeastern regions. In the second stage, 6,500 students were selected from the 1 5 chosen institutions using stratified proportional sampling with simple random sampling. Code numbers were created to protect the privacy of students. From a total of 6,500 students, 3,570 first- to fourth-year nursing students were sampled using simple random sampling. The inclusion criteria for participation in this study were being aged 18 years or older and a nursing student at the institute for at least 6 months during the study period. Inappropriate responses to items, such as responding to only part of the general information in the WHOQOL-BREF, served as the exclusion criteria. Measurement Respondents were obtained using self-assessment questionnaires for data collection. They were contacted, given full details about the study, and asked to participate voluntarily. There were two sections to the questionnaire. The first section comprised questions designed to obtain information about respondents’ socioeconomic characteristics, including age, gender, academic year, and lifestyle/health information (for example, smoking habits, alcohol consumption, sports and recreation activity, number of hours using electronic devices and personal medical history). The WHOQOL-BREF-THAI was used to assess the respondents’ QOL. Permission to use the Thai WHOQOL-BREF for data collection was obtained from Bureau of Mental Health Academic Affairs: BMHA Department of Mental Health: DMH, Ministry of Public Health, Thailand. This instrument consists of 26 items, with the first two assessed and scored individually to assess the overall sense of QOL (Q1) and satisfaction with general well-being (Q2). Items 3-26 are used to assess four domains: the physical health (7 items), psychological health (6 items), social relationships (3 items), and environment domains (8 items). The two additional questions assessing overall QOL and general health were not considered to be part of any of the four domains and were thus eliminated from the factor analysis in this study. A 5-point Likert response scale is used in the instrument, so these items were scored from 1 (very poor/dissatisfied) to 5 (very good/very satisfied) on a 5-point scale. According to the guidelines, raw WHOQOL domain scores were converted to a 4-20 scale. After reversing the raw scores of Q 3 , Q 4 and Q 26 , the domain scores were calculated by adding the scores of each domain’s items together. The scores were then linearly transformed to a 0-100 scale. Higher scores indicate a higher level of QOL. Several previous studies have demonstrated the WHOQOL-BREF’s validity and reliability. 1 The Cronbach’s alpha values of the physical health, psychological health, social relationships, and environment domains were 0.68, 0.71, 0.76, and 0.88, respectvely. 1 Data collection Before beginning the survey, the dean of each nursing college/university granted permission to collect data, and all participants provided informed consent. The Roi-Et Rajabhat University Ethics Committee for Human Research approved the study protocol (Reference No. RERU-EC 013/2567). The date of approval was the 15th of January 2024. All participants were informed of the study’s objectives and the confidentiality of the data, and they were assured that the data would be used solely for research purposes and that refusing to participate would have no bearing on their current or future studies. Students were not compensated or otherwise encouraged to participate in the study. Respondents were free to leave the study at any time. Sample size The sample size was determined using the formula “sample size = number of items X number of participants,” which is commonly used in survey development research. Each questionnaire item should have a sample size of 5 to 10 participants. 33 Accordingly, our study included 3,570 nursing students from 15 universities primarily located in the northeast of Thailand. Consequently, larger sample sizes may yield more significant factor loadings and more generalizable results. The study involved nursing students aged 18 and above who were enrolled as nursing students at the institute during the study period, and incomplete items of the Thai version of the WHOQOL-BREF served as the exclusion criteria. To avoid overfitting of the models, the exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted on a random split of the participants into two subsamples (group 1, n = 2,000, and group 2, n = 1,570). Statistical analysis Regarding the demographic characteristics of the participants, descriptive statistics, with means and standard deviations for continuous variables and frequency and percentages for categorical data, were used. The floor and ceiling effects of the questions were analysed by considering the percentages of respondents selecting the lowest and highest response options, respectively. In this context, items with percentages of 15% or lower were deemed free from these effects. The discriminative capacity of the items was evaluated using the corrected item-rest polyserial correlation, with acceptable indices defined as those exceeding 0.20. 34 The scree plot and parallel analysis (based on principal component analysis) was used with subsample group 1 to examine the number of components in the EFA for the WHOQOL-BREF measurement model. The structure of factors was further examined using primary axis factoring in conjunction with varimax rotation. Factor loadings less than 0.40 were suppressed, while item cross-loadings greater than 0.20 were deleted sequentially. Communality represents the percentage of variance in the total items accounted for by all factors. Furthermore, factor loadings were employed to compute the average variance extracted (AVE) and composite reliability (CR). CFA was performed to evaluate the WHOQOL-BREF factorial models. The weighted least squares means, and variance adjusted (WLSMV) approach was used to perform CFA on the polychoric correlation matrix. 35 The model’s fit was evaluated using goodness-of-fit indices (χ 2 /df ), Tucker-Lewis index (TLI), comparative fit index (CFI), and root mean square error of approximation (RMSEA). Values of χ 2 /df ≤ 5.00, CFI and TLI ≥ 0.90, and RMSEA ≤ 0.10 indicate an acceptable fit, while values of χ 2 /df ≤ 2.00, CFI and TLI ≥ 0.95, and RMSEA ≤ 0.05 indicate a good fit. 36 Reliability analysis was carried out using internal consistency reliability for each dimension. Internal consistency was assessed using Cronbach’s alpha coefficient. Internal consistency reliability was evaluated using CR and Cronbach’s alpha. When the values for the four subscales are greater than 0.60, CR is considered acceptable, and a Cronbach’s alpha value greater than 0.70 for all subscales is considered satisfactory. 35 Likewise, the Pearson correlation coefficient was employed to assess criterion-related validity by determining the degree to which each item correlated with two generic items, namely, overall QOL and general health, which were used as the criteria. Furthermore, the corrected item-total correlations of the four subscales represent the relationships between each of the WHOQOL-BREF-THAI items and its own subscale, with that item deleted. Convergent validity was assessed using the AVE. The AVE must be equal to or more than 0.50 to establish convergent validity, indicating that the variance of the construct accounts for more than 50% of its variation. 37 Discriminant validity was also used to determine whether the four WHOQOL-BREF domains were unique factors. Pearson’s correlation (r) values below 0.85 demonstrated discriminant validity between the variables. 37 The intercorrelations matrix and the temporal stability of the WHOQOL-BREF subscale scores were both investigated using Pearson correlations. Results This study recruited 3,570 nursing students. The majority of those who completed the questionnaire (92.3%) were female, with a mean age of 20.29 (±2.12) years. More than two-thirds (72.6%) of these individuals lived on campus. About 28.4% of these participants reported alcohol consumption. Table 1 shows the characteristics of the nursing students (n = 3,570). Table 1. Demographic characteristics of the participants (n = 3,570). Characteristic Mean ±SD or n (%) Gender Male 375 7.7 Female 3,295 92.3 Age in years Mean (±SD) 20.29 (±2.12) Median (min: max) 20 (18:35) Academic year First year 1,208 33.8 Second year 1,060 29.7 Third year 761 21.3 Fourth year 541 15.2 GPA Mean (±SD) 3.18 (±0.37) Median (min: max) 3.21(1.88:4.00) Residence Live on campus 2,567 72.6 Live off campus 969 27.4 Income Mean (±SD) 5,191.42 (±2423.48) Median (min: max) 5,000 (1,000:18,000) Smoking habit No 3,442 96.4 Yes 128 3.6 Alcohol consumption No 2,557 71.6 Yes 1,013 28.4 Table 2 shows the results of the descriptive analysis for the 24 subscales of the WHOQOL-BREF. Each item had a range of 1-5 points, and no floor or ceiling effects were observed for any of the items. In addition, all items had polyserial item-rest correlation coefficients larger than 0.20, indicating their discriminative ability. In addition, Cronbach’s alpha values varied between 0.59 and 0.81 when each item was removed. Table 2. Distribution of responses and discrimination of the items. Item Mean (±SD) Response (%) Item-rest correlation Cronbach’s alpha if an item was deleted 1 2 3 4 5 1 3.39 (±0.91) 7.7 15.9 45.6 23.5 7.3 0.41 0.75 2 3.51 (±0.89) 13.4 36.0 40.0 9.2 1.4 0.42 0.79 3 2.72 (±0.93) 11.1 30.6 37.7 15.8 4.8 0.33 0.69 4 3.52 (±0.95) 8.2 24.2 37.6 21.1 8.9 0.50 0.79 5 3.09 (±0.97) 5.6 24.8 43.5 21.6 8.5 0.52 0.81 6 3.42 (±0.92) 1.4 14.2 40.8 30.3 13.3 0.67 0.78 7 3.26 (±0.81) 1.1 14.1 50.0 28.0 6.8 0.64 0.68 8 3.52 (±0.92 1.6 12.0 38.7 32.1 15.5 0.70 0.79 9 2.98 (±0.93) 1.7 11.3 37.8 31.6 17.8 0.66 0.81 10 3.10 (±0.93) 12.3 29.8 36.4 15.9 5.6 0.30 0.69 11 3.50 (±0.91) 8.7 23.4 37.6 20.4 9.9 0.50 0.81 12 3.59 (±0.93) 7.9 20.1 4.4 19.8 7.8 0.53 0.78 13 3.54 (±0.92) 1.4 7.0 27.9 30.6 33.2 0.72 0.68 14 3.78 (±0.89) 1.4 7.0 27.9 30.6 33.2 0.72 0.75 15 3.49 (±0.89) 1.4 11.9 40.7 31.6 14.4 0.74 0.82 16 3.53 (±0.91) 1.7 12.0 37.5 30.8 18.0 0.72 0.79 17 3.23 (±0.89) 2.4 14.9 47.1 25.2 10.4 0.63 0.65 18 3.47 (±0.91) 1.3 12.0 42.2 30.8 13.7 0.73 0.61 19 3.41 (±0.89) 1.1 12.1 42.8 31.6 12.4 0.72 0.59 20 3.08 (±0.89) 2.9 17.4 47.3 23.8 8.6 0.60 0.69 21 3.32 (±0.92) 1.7 13.1 43.8 29.4 12.0 0.73 0.80 22 3.24 (±0.91) 2.0 14.1 44.5 28.5 10.9 0.69 0.59 23 3.83 (±0.94) 7.9 22.8 35.0 20.2 14.1 0.66 0.66 24 3.75 (±0.91) 7.8 22.8 35.1 20.2 14.1 0.50 0.70 25 3.90 (±0.89) 1.3 7.0 27.9 30.6 33.2 0.72 0.58 26 3.60 (±0.89) 1.1 8.7 39.5 31.9 18.8 0.72 0.81 Following the random selection of 2,000 participants for EFA, scree plot and parallel analysis of the matrix revealed that a four-factor solution could be extracted. The matrix of rotational factor loading was statistically significant. The group 1 subsample yielded four components with eigenvalues greater than 1 in the initial analyses. The scree plot and the eigenvalue > 1 criterion revealed that the four factors resembled the original structure (eigenvalues: 10.52, 4.78, 1.52, and 1.34), and this model explained 75.6% of the total variance. The KMO measure verified the sampling adequacy (KMO = 0.97) and the significant result of Bartlett’s test of sphericity (p-value < 0.001), which indicated that the data in this study were suitable for factor analysis. Moreover, most of communalities were close to 1 (0.61-0.83), indicating that the model explains most of the variation in those variables. Table 3 shows the factor loadings for each WHOQOL-BREF item, with factor loadings greater than 0.50 indicating acceptable loading. Table 3. Factor loading values for each item of the scale (n = 2,000). Item Factor loading a Communality Physical health Psychological health Social relationships Environment Pain and discomfort 0.89 0.81 Energy and fatigue 0.88 0.81 Sleep and rest 0.59 0.83 Activities of daily living 0.79 0.75 Dependence on medication 0.55 0.78 Working capacity 0.55 0.79 Mobility 0.59 0.77 Positive feelings 0.79 0.86 Concentration 0.85 0.78 Self-esteem 0.86 0.83 Bodily appearance 0.87 0.73 Negative feelings 0.83 0.61 Spirituality 0.75 0.69 Personal relationships 0.72 0.91 Social support 0.71 0.90 Sexual activity 0.71 0.91 Physical safety & security 0.82 0.73 Home environment 0.80 0.70 Financial resources 0.83 0.68 Access to health services 0.84 0.76 Information 0.84 0.72 Leisure time 0.82 0.81 Physical environment 0.85 0.86 Transport 0.84 0.71 KMO 0.97 Cronbach’s alpha 0.73 0.82 0.72 0.84 Total of Cronbach’s alpha 0.94 Cumulative % 75.6 a Extraction method: Principal component analysis. The WHOQOL-BREF measurement model, comprising 24 items distributed across four domains—physical health (7 items), psychological health (6 items), social relationships (3 items), and environment—was fitted using an unweighted least squares CFA. The correlation coefficients between the domains varied from 0.35 to 0.68, and the standardized regression weights ranged from 0.32 to 0.92 ( Figure 1 ). Based on the four specified fit criteria, the model demonstrated an acceptable fit to the data (χ 2 = 348.26/df = 113; RMSEA = 0.05; GFI = 0.97; and TLI = 0.91). Although the large sample size made the chi-square test inadequate for assessing model fit, other indices revealed that the model still fitted the data well. In addition, except for the factor-constrained items, all model items were significantly loaded onto their respective factors (all p-values < 0.05), with no significant tests remaining. Figure 1. Four-domain model of the WHOQOL-BREF-THAI and standardized regression coefficients. In all cases, the Pearson correlation coefficients between the WHOQOL-BREF domains ranged from 0.35 to 0.68, indicating fair to moderate correlations and indicating that these scales were moderately to highly discriminative. The convergent validity of the modified WHOQOL-BREF measurement model was assessed in the context of this study using CR and AVE. In the current study, all subscales of the WHOQOL-BREF exhibited CR values exceeding the threshold of 0.70 (ranging between 0.76 and 0.95), indicating high internal consistency ( Table 4 ). This suggests that the items within each subscale cohesively measure the same underlying construct. AVE calculations showed that all WHOQOL-BREF subscales achieved convergence, with the following AVE values: physical health = 0.50, psychological health = 0.68, social relationships = 0.51, and environment = 0.69. Table 4. Convergent validity and internal consistency of the WHOQOL-BREF. WHOQOL-BREF domain Composite reliability (CR) Average variance extracted (AVE) Cronbach’s alpha Item-total correlation Physical health 0.73 0.50 0.73 0.33-0.53 Psychological health 0.82 0.68 0.82 0.52-0.70 Social relationships 0.72 0.51 0.72 0.69-0.71 Environment 0.84 0.69 0.84 0.60-0.70 Total - - 0.94 0.33-0.71 According to the Cronbach’s alpha values, which were 0.94 for the overall scale, 0.73 for physical health, 0.82 for psychological health, 0.72 for social relationships, and 0.84 for environment, the WHOQOL-BREF exhibited adequate internal reliability as all values were above 0.70 ( Table 4 ). In addition, the CR values of the four domains, ranging from 0.76 to 0.95, indicated evidence of acceptable reliability. With a Cronbach’s alpha value of 0.84, the environment dimension demonstrated even greater consistency. These findings suggest that the items within these dimensions cohesively measure their intended constructs. Furthermore, the internal consistency of this scale was good, as evidenced by the item-rest correlations, which were higher than 0.30 for all four subscales, and the corrected item-rest correlations, which varied from 0.33 to 0.72 for the entire scale. The strong magnitude of the correlations between all four domains indicated good discriminant validity ( Figure 1 ). Furthermore, r values between the variables were all smaller than 0.85, confirming their discriminant validity. The inter-correlations matrix among the four subscales of the WHOQOL-BREF and overall QOL demonstrated strong inter-correlation values ( Figure 1 ). Notably, the subscales of environment and psychological health showed the strongest inter-correlation among the four domains (r = 0.68). The correlation between each subscale item and the general categories, which are overall QOL (Q1) and general health (Q2), is significant (p-value < 0.001). Each individual question had a moderate-to-fair level of correlation with Q1 (0.22 ≤ r ≤ 0.52, p-value < 0.001) and Q2 (0.22 ≤ r ≤ 0.66, p-value < 0.001). According to the findings, each subscale item demonstrated a suitable degree of criterion-related validity, showing consistency in terms of direction and connection with the two criteria, as indicated in Table 5 . Table 5. Criterion-related validity of WHOQOL-BREF domains and items (n = 2,000). Domain Criterion-related validity Overall QOL (Q 1 a ) General health (Q a 2 ) Domain 1: Physical health Pain and discomfort 0.26 * 0.36 * Energy and fatigue 0.44 * 0.52 * Sleep and rest 0.24 * 0.22 * Activities of daily living 0.22 * 0.45 * Dependence on medication 0.23 * 0.26 * Working capacity 0.25 * 0.27 * Mobility 0.30 * 0.31 * Domain 2: Psychological health Positive feelings 0.41 * 0.27 * Concentration 0.52 * 0.39 * Self-esteem 0.40 * 0.48 * Bodily appearance 0.42 * 0.43 * Negative feelings 0.41 * 0.47 * Spirituality 0.33 * 0.66 * Domain 3: Social relationships Personal relationships 0.30 * 0.32 * Social support 0.29 * 0.59 * Sexual activity 0.28 * 0.33 * Domain 4: Environment Physical safety and security 0.40 * 0.66 * Home environment 0.37 * 0.65 * Financial resources 0.35 * 0.62 * Access to health services 0.37 * 0.61 * Information 0.35 * 0.59 * Leisure time 0.37 * 0.61 * Physical environment 0.38 * 0.58 * Transport 0.27 * 0.53 * All 24 WHOQOL-BREF items 0.46 * 0.27 * a Criterion-related validity refers to the strength of the Pearson correlation between each domain/its items and the two criterion items, i.e., overall QOL (Q1) and general health (Q2). * p - value < 0.001. Discussion To our knowledge, this is the first study that aims to examine the psychometric properties of the WHOQOL-BREF among nursing students. Overall, the current findings support the use of WHOQOL-BREF- THAI with Thai nursing students in northeast Thailand. The reliability and criterion-related validity were excellent, and the fit of the hypothesized four domains of QOL was acceptable. Furthermore, the item-scale correlation matrix for the WHOQOL-BREF measurement revealed that all items in the physical health (7 items), psychological health (6 items), social relationships (3 items), and environment (8 items) domains had extremely high correlation coefficients with their respective domains. This result is comparable to a prior study in Asia that aimed to evaluate the psychometric properties of the WHOQOL-BREF questionnaire among disabled students in Malaysian higher learning institutions. 15 Moreover, the CFA results from a study of adults with disabilities and adults from the general population in Singapore also supported the four domains. 18 In addition, most of the communality values were close to 1, indicating that the extracted factors explained most of the variance in each individual item. 38 These results were in line with a study on the validity and reliability of the WHOQOL-BREF in a pregnant population. 39 Concerning data distribution, no floor or ceiling effects were observed in any of the items. These findings suggest that the WHOQOL-BREF instrument can effectively measure the responsiveness to change in nursing students with elevated scale scores. 40 Item analysis revealed strong discrimination indices for each scale. All item-total correlations were highly and positively correlated with the total score, demonstrating the scale’s homogeneity. These indices revealed that by utilizing the Thai version of the WHOQOL-BREF items, high and low scores on this scale could be distinguished. These results were comparable with a previous study that aimed to evaluate the psychometric properties of this tool in the Vietnamese young adult population. 28 According to the CFA results, the goodness-of-fit indices were acceptable, and the four main factor structures with eigenvalues greater than 1 explained 75.6% of the total variance. The WHOQOL-BREF was confirmed in this sample to be consistent with earlier WHOQOL-BREF research. 13 , 17 , 23 , 24 , 26 Although previous research suggested that WHOQOL-BREF factor extraction could yield different solutions in some instances, 25 , 27 , 29 the four-factor solution was considered essential for a better model fit, as the former has disadvantages in terms of inter-item correlations. Similar research in China supported the use of the WHOQOL-BREF for medical students. 41 Another finding from our study that demonstrates the structural validity of the tool is that the correlation values between its sub-dimensions were positive and significant across all dimensions. These results are comparable with a previous study that aimed to evaluate the psychometric properties of this tool in an adult population. 18 The Cronbach’s alpha coefficients for the total score and the four domain scores ranged from 0.85-0.97, and the CR values above 0.7 revealed that the WHOQOL-BREF-THAI scores and subscales had good internal consistency, comparable to the Cronbach’s alpha values of the original scale. 1 This coefficient ranged from good to excellent in previous studies involving both nonclinical and clinical adult samples. 13 , 15 – 17 , 19 , 23 , 42 Hence, the data collectively show that the WHOQOL-BREF-THAI demonstrates strong internal consistency across a variety of demographics and languages. Considering the internal consistency scores of the WHOQOL-BREF domains, the environmental domain had the highest Cronbach’s alpha, which was consistent with a previous study that examined the validity and reliability of the WHOQOL-BREF in Vietnamese young adults. 28 The low Cronbach’s alpha in the social relationships domain should be interpreted with caution due to the use of only three item scores, instead of the required four, for internal reliability assessment. 35 Moreover, the test-retest reliability results of this study, which classify the WHOQOL-BREF-THAI as an excellent tool, are consistent with a previous study. 20 The association between the mean scores of each item/domain scores with the single item of overall QOL was used to evaluate the criterion-related validity. As hypothesized, all domains showed significant positive correlations with items on overall QOL and general health. The results show that all items in the scale and its four domains have adequate criterion-related validity, with significant relationships with the two criteria. This result is in line with the study that aimed to examine the performance of the WHOQOL-BREF-THAI in assessing the QOL among Thai college students. 13 Furthermore, our findings showed that the psychological health domain had the greatest impact on overall QOL, followed by the environment domain. Similarly, the environment domain had the greatest impact on health satisfaction, followed by the psychological health domain. This outcome is consistent with earlier research findings, 18 indicating the importance of psychological well-being for overall QOL and health. The validity findings show that the WHOQOL-BREF-THAI is well validated for Thai nursing students. These findings are in line with previous studies, 13 , 39 which also found that this tool was well validated for both Thai college students 13 and the pregnant population. 39 To assess convergent validity, the AVE calculation of all four subscales was used to evaluate the WHOQOL-BREF. The results demonstrated that the AVE for all subscales was greater than 0.50, which corresponded to the convergent validity acceptance criterion. In addition, convergent validity was demonstrated by the significant positive correlations between the scale domains and overall QOL, as well as the positive correlations among all four WHOQOL-BREF domains. Moreover, several international studies have found the WHOQOL-BREF to have convergent and discriminant validity. 1 , 13 , 24 , 26 These findings confirm the validity and reliability of the WHOQOL-BREF Thai version as an instrument for measuring positive emotional states. This implies that this scale could be beneficial for assessing QOL in healthcare personnel and health science students, such as nursing students. The results of the intercorrelations matrix between the four WHOQOL-BREF subscales and overall QOL suggested that there were strong item-domain correlations, particularly between the physical health and environment domains (r = 0.68). This may indicate that the good environment provided to nursing students is associated with improved physical health. This finding is comparable with prior study that aimed to evaluate psychometric properties of the WHOQOL-BREF questionnaire among disabled students. 15 Strengths and limitations This study is unique in that it examines the WHOQOL-BREF-THAI in a large sample of Thai undergraduate nursing students. Because the participant-to-item ratio was adequate, the criteria for component analysis were met, and bias resulting from the number of observations was reduced. Our research has some limitations because our sample was made up entirely of nursing students. Because of the diversity of characteristics, this sample cannot be accurately generalized to other non-clinical undergraduate students, as they may differ in terms of socioeconomic status, freedom, and health. Since the research was cross-sectional, the data could not demonstrate test-retest reliability over time. Conclusion According to our findings, the WHOQOL-BREF is a reliable and valid tool for healthcare providers to use for assessing QOL among Thai nursing students. QOL is likely to have an impact on their future clinical success. Therefore, the WHOQOL-BREF can be an essential tool for researching the factors influencing the QOL of nursing students, with implications for nursing education. Ethical considerations This research was approved by the Roi-Et Rajabhat University Ethics Committee for Human Research (Reference No. RERU-EC 013/2567). The date of approval was the 15th of January 2024. Ethics Committees for Human Research, based on the Declaration of Helsinki and the ICH Good Clinical Practice Guidelines Written informed consent was obtained from all patients. Participants were informed that they could withdraw from the study at any time without providing a reason. The confidentiality of participant data was ensured throughout the entire study. Data availability Figshare: Validation of the Thai version of the World Health Organization’s Quality of Life Scale (WHOQOL-BREF-THAI) among Thai Nursing Students in Northeast Thailand: A multi-canter study. The data provide do not have subheading and this project contains the following underlying data Figshare:, DOI: https://doi.org/10.6084/m9.figshare.28136420.v2 43 The project contains the following underlying data: • Data.xlsx Data are available under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0). Extended data Figshare: Validation of the Thai version of the World Health Organization’s Quality of Life Scale (WHOQOL-BREF-THAI) among Thai Nursing Students in Northeast Thailand: A multi-canter study. The data provide do not have subheading and this project contains the following underlying data Figshare:, DOI: https://doi.org/10.6084/m9.figshare.28136420.v2 43 The project contains the following extended data: • Ethical consideration • Questionnaires (including the English version of WHOQOL-BREF) Data are available under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0). Acknowledgements The authors would like to express their gratitude to all nursing schools for assisting with student data collection. The authors would like to thank their research colleagues at all participating nursing institutes for their help with subject recruitment and data collection. Without the cooperation of all nursing students, this study would not have been possible. 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Publisher Full Text Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 27 Feb 2025 ADD YOUR COMMENT Comment Author details Author details 1 Faculty of Nursing, Roi Et Rajabhat University, Kho Kaew Subdistrict, Selaphum District, Roi Et, 45120, Thailand 2 Faculty of Nursing, Udon Thani Rajabhat University, Udon Thani, Udon Thani, Thailand 3 Faculty of Nursing, Roi Et Rajabhat University, Ko Kaeo Subdistrict, Selaphum District, Roi Et, Thailand 4 Faculty of Nursing, Nakhon Ratchasima Rajabhat University, Nakhon Ratchasima, Nakhon Ratchasima, Thailand 5 Department of Obstetric and Gynaecology, Udon Thani Hospital, Udon Thani, Udon Thani, Thailand Ueamporn Summart Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Methodology, Project Administration, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Monthida Sangruangake Roles: Conceptualization, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Jumrusluk Charoensaen Roles: Conceptualization, Methodology, Writing – Original Draft Preparation Wiraporn Suebsoontorn Roles: Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Metha Songthamwat Roles: Data Curation, Formal Analysis, Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This research project was supported by The Fundamental Fund: FF 2024, Roi Et Rajabhat University (Grant Number 203446). We confirm that the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (3) version 3 Revised Published: 22 Jul 2025, 14:241 https://doi.org/10.12688/f1000research.161251.3 version 2 Revised Published: 23 May 2025, 14:241 https://doi.org/10.12688/f1000research.161251.2 version 1 Published: 27 Feb 2025, 14:241 https://doi.org/10.12688/f1000research.161251.1 Copyright © 2025 Summart U et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Summart U, Sangruangake M, Charoensaen J et al. Validation of the Thai version of the World Health Organization’s Quality of Life Scale (WHOQOL-BREF-THAI) among Thai nursing students in northeast Thailand: A multi-centre study [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :241 ( https://doi.org/10.12688/f1000research.161251.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 27 Feb 2025 Views 0 Cite How to cite this report: do Carmo Cruz Robazzi ML and de Souza Terra F. Reviewer Report For: Validation of the Thai version of the World Health Organization’s Quality of Life Scale (WHOQOL-BREF-THAI) among Thai nursing students in northeast Thailand: A multi-centre study [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :241 ( https://doi.org/10.5256/f1000research.177256.r375812 ) The direct URL for this report is: https://f1000research.com/articles/14-241/v1#referee-response-375812 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 21 May 2025 Maria Lúcia do Carmo Cruz Robazzi , University of São Paulo, São Paulo, Brazil Fabio de Souza Terra , School of Nursing, Federal University of Alfenas, Alfenas, Minas Gerais, Brazil Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.177256.r375812 This study, which validated the Thai version of the WHOQOL-BREF in a robust sample of 3,570 nursing students from northeastern Thailand, presents relevant results regarding the psychometric properties of the instrument in this specific population. The analysis identified a four-domain ... Continue reading READ ALL This study, which validated the Thai version of the WHOQOL-BREF in a robust sample of 3,570 nursing students from northeastern Thailand, presents relevant results regarding the psychometric properties of the instrument in this specific population. The analysis identified a four-domain structure with 24 items, demonstrating good internal consistency (alpha > 0.70) and convergent validity (AVE > 0.50). The authors pertinently conclude that the WHOQOL-BREF-THAI is a valid and reliable tool for assessing the quality of life of these students, with potential application in nursing research and education. Considering the validation context – nursing students in all four years of undergraduate study in northeastern Thailand – the study proves to be interesting and necessary. The cited literature is relevant to the topic. However, it is observed that only 32.55% of the 43 references presented are from the last five years. It is therefore suggested that the authors seek to include a greater number of updated references, aiming to reach at least 50% of more recent citations. Although subsequent and suggested studies in this review do not focus on the validation of the WHOQOL-BREF in nursing students or analyze other instruments, some may enrich the discussion of the present work. The following references, for example, could be considered in the Introduction, Method, or Discussion to increase the percentage of recent studies: ( refer 1, 2 , 3 and 4 ) Summary: The objective presented in the summary is consistent with that of the body of the text. The summary is clear, and the conclusion adequately responds to the proposed objective. Introduction: Well-presented and clear, the introduction directs the reader to the gap in the literature regarding the psychometric properties of the WHOQOL-BREF in Thai nursing students, clearly establishing the main objective of the study. It is important to note that the authors used the WHO's concept of quality of life (QOL), the organizing principle of the original WHOQOL, which in its construction used this same concept of QOL as a theoretical framework. Method: The study design is detailed enough to allow for replication by other researchers. However, as it is a validation study, it is suggested that it also be characterized as a “methodological study.” The statistical analysis employed is appropriate, and the sample of 3,570 Thai nursing students was adequately divided for the exploratory (n=2000) and confirmatory (n=1570) analyses. Results: The results are presented clearly through five tables and one figure, highlighting the main findings that address the study's objective, which is expected for research of this nature. Discussion: The discussion is adequate and based on relevant literature, although the inclusion of more recent studies could enrich it. Strengths and Limitations: Adequately presented. However, if the authors aimed to study only nursing students, we do not understand this element as a limitation; other authors and new studies can carry out the validation process with different students. Conclusions: The conclusions are consistent with the objective and based on the results. Data Availability: The data is accessible in the Figshare repository. In summary, this study significantly contributes to the understanding of the psychometric properties of the WHOQOL-BREF in Thai nursing students. The suggested updating of references may further strengthen the theoretical foundation and the discussion of the results. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes References 1. Putri GP, Inggrini I, Tanjung NAD, Pakpahan M, et al.: The Lifestyle and Quality of Life Among Nursing Students. J Holist Nurs . 2025; 43 (1): 18-25 PubMed Abstract | Publisher Full Text 2. Galgam FA, Abdalla A, Shahin M, Yousif M, et al.: Assessing the quality of life among African medical and health science students using the WHOQOL-BREF tool. PeerJ . 2025; 13 : e18809 PubMed Abstract | Publisher Full Text 3. Hall LA, Lee Ridner S, Crawford TN: The Psychometric Properties of the World Health Organization Quality of Life-BREF Questionnaire in College Students. J Nurs Meas . 2024; 32 (2): 256-266 PubMed Abstract | Publisher Full Text 4. Santin Júnior LJ, Martins BG, Campos JADB, Vazquez ACS, et al.: Psychometric properties of the Burnout Assessment Tool - General version in nursing workers. Rev Lat Am Enfermagem . 2025; 33 : e4425 PubMed Abstract | Publisher Full Text Competing Interests: Nursing and Occupation Health Reviewer Expertise: Nursing; Ocuupational Health We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT do Carmo Cruz Robazzi ML and de Souza Terra F. Reviewer Report For: Validation of the Thai version of the World Health Organization’s Quality of Life Scale (WHOQOL-BREF-THAI) among Thai nursing students in northeast Thailand: A multi-centre study [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :241 ( https://doi.org/10.5256/f1000research.177256.r375812 ) The direct URL for this report is: https://f1000research.com/articles/14-241/v1#referee-response-375812 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 09 Aug 2025 Ueamporn Summart , Faculty of Nursing, Roi Et Rajabhat University, Kho Kaew Subdistrict, Selaphum District, 45120, Thailand 09 Aug 2025 Author Response Thank you for all of your suggestions. After we considered all of your suggestions, we agreed with your opinions to edit and revise our manuscript as follows: 1) We edited our ... Continue reading Thank you for all of your suggestions. After we considered all of your suggestions, we agreed with your opinions to edit and revise our manuscript as follows: 1) We edited our citation following your suggestion in the introduction part and discussion part. 2) We edited our study design into "a methodological study." Please see our revised manuscript. 3) Limitation: Thanks for your suggestions. We deleted this statement from this part and added another limitation regarding data being collected at a single point in time. Thank you for all of your suggestions. After we considered all of your suggestions, we agreed with your opinions to edit and revise our manuscript as follows: 1) We edited our citation following your suggestion in the introduction part and discussion part. 2) We edited our study design into "a methodological study." Please see our revised manuscript. 3) Limitation: Thanks for your suggestions. We deleted this statement from this part and added another limitation regarding data being collected at a single point in time. Competing Interests: No competing interests were disclosed. Close Report a concern Author Response 09 Aug 2025 Ueamporn Summart , Faculty of Nursing, Roi Et Rajabhat University, Kho Kaew Subdistrict, Selaphum District, 45120, Thailand 09 Aug 2025 Author Response I would like to express my gratitude for your diligent efforts to comment on and suggestions for improving our manuscript. We appreciated all of this and attempted to edit this ... Continue reading I would like to express my gratitude for your diligent efforts to comment on and suggestions for improving our manuscript. We appreciated all of this and attempted to edit this manuscript following your comments. If you have any comments, we do not hesitate to edit our manuscripts following your comments and send them back to your process as fast as possible. I would like to express my gratitude for your diligent efforts to comment on and suggestions for improving our manuscript. We appreciated all of this and attempted to edit this manuscript following your comments. If you have any comments, we do not hesitate to edit our manuscripts following your comments and send them back to your process as fast as possible. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 09 Aug 2025 Ueamporn Summart , Faculty of Nursing, Roi Et Rajabhat University, Kho Kaew Subdistrict, Selaphum District, 45120, Thailand 09 Aug 2025 Author Response Thank you for all of your suggestions. After we considered all of your suggestions, we agreed with your opinions to edit and revise our manuscript as follows: 1) We edited our ... Continue reading Thank you for all of your suggestions. After we considered all of your suggestions, we agreed with your opinions to edit and revise our manuscript as follows: 1) We edited our citation following your suggestion in the introduction part and discussion part. 2) We edited our study design into "a methodological study." Please see our revised manuscript. 3) Limitation: Thanks for your suggestions. We deleted this statement from this part and added another limitation regarding data being collected at a single point in time. Thank you for all of your suggestions. After we considered all of your suggestions, we agreed with your opinions to edit and revise our manuscript as follows: 1) We edited our citation following your suggestion in the introduction part and discussion part. 2) We edited our study design into "a methodological study." Please see our revised manuscript. 3) Limitation: Thanks for your suggestions. We deleted this statement from this part and added another limitation regarding data being collected at a single point in time. Competing Interests: No competing interests were disclosed. Close Report a concern Author Response 09 Aug 2025 Ueamporn Summart , Faculty of Nursing, Roi Et Rajabhat University, Kho Kaew Subdistrict, Selaphum District, 45120, Thailand 09 Aug 2025 Author Response I would like to express my gratitude for your diligent efforts to comment on and suggestions for improving our manuscript. We appreciated all of this and attempted to edit this ... Continue reading I would like to express my gratitude for your diligent efforts to comment on and suggestions for improving our manuscript. We appreciated all of this and attempted to edit this manuscript following your comments. If you have any comments, we do not hesitate to edit our manuscripts following your comments and send them back to your process as fast as possible. I would like to express my gratitude for your diligent efforts to comment on and suggestions for improving our manuscript. We appreciated all of this and attempted to edit this manuscript following your comments. If you have any comments, we do not hesitate to edit our manuscripts following your comments and send them back to your process as fast as possible. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 27 Feb 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 Version 3 (revision) 22 Jul 25 read Version 2 (revision) 23 May 25 read read Version 1 27 Feb 25 read Maria Lúcia do Carmo Cruz Robazzi , University of São Paulo, São Paulo, Brazil Fabio de Souza Terra , Federal University of Alfenas, Alfenas, Brazil Edison Luiz Devos Barlem , Universidade Federal do Rio Grande, Rio Grande, Brazil Evija Nagle , Rīga Stradiņš University, Rīga, Latvia Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Nagle E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 05 Jan 2026 | for Version 3 Evija Nagle , Rīga Stradiņš University, Rīga, Latvia 0 Views copyright © 2026 Nagle E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The submitted manuscript presents a large-scale, multi-center psychometric validation study of the WHOQOL-BREF-THAI in a population of nursing students in northeastern Thailand. The research topic is relevant and topical, and the sample size is excellently suited for factor analysis, allowing for the reasonable use of split-sample exploratory (EFA) and confirmatory factor analysis (CFA). Overall, the study provides a significant empirical contribution to the use of quality-of-life assessment instruments in the context of nursing education. From a methodological perspective, random allocation of the sample for EFA (n = 2000) and CFA (n = 1570) is appropriate and consistent with best practice in psychometric research. The reported KMO scores, Bartlett's test of sphericity, factor loadings, and total variance explained indicate very good data suitability for factor analysis. Internal consistency measures (Cronbach α and composite reliability) as well as convergent validity estimates (AVE) for all subscales are at an acceptable or high level, which generally confirms the reliability of the instrument. At the same time, there are several aspects that should be clarified for the manuscript to fully comply with high-level psychometric reporting standards. First, although the term “exploratory factor analysis” is used in the text, principal component analysis (PCA) was used to obtain the factors. This methodological choice should be clearly acknowledged and theoretically justified, considering the differences between PCA and total factor analysis in the context of construct validation. Second, the choice of the WLSMV estimation method used in the CFA analysis should be more clearly justified in relation to the nature of Likert-type ordinal data to improve the transparency and reproducibility of the study. The description of the cultural adaptation process in the manuscript is limited. Given that the WHOQOL-BREF-THAI is an adapted instrument, it would be useful to briefly but clearly describe the previous translation, cultural adaptation and content validation steps, even if they were carried out in other studies. This would strengthen the argument for construct equivalence in the nursing student population. Furthermore, the discriminant validity assessment is mainly based on interfactor correlations; the inclusion of additional criteria, such as the Fornell–Larcker approach, would further strengthen the validity evidence. In the discussion section, the results are generally well integrated into the international literature, however, it is recommended to expand the limitations section by more clearly emphasizing the cross-sectional design, the use of self-report data and the lack of test–retest reliability. Even if longitudinal data are not available in this study, these aspects should be clearly highlighted as directions for future research. It would also be useful to discuss more broadly the practical applications of the instrument – ​​for example, in screening student well-being, institutional monitoring or in planning targeted support intervention programs in nursing education. In conclusion, the study is scientifically sound and based on a strong empirical foundation. By introducing methodological refinements and deepening the analysis of cultural adaptation and constraints, the manuscript would be significantly strengthened both methodologically and practically. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Nagle E. Peer Review Report For: Validation of the Thai version of the World Health Organization’s Quality of Life Scale (WHOQOL-BREF-THAI) among Thai nursing students in northeast Thailand: A multi-centre study [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :241 ( https://doi.org/10.5256/f1000research.185381.r442205) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-241/v3#referee-response-442205 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Barlem E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 07 Jul 2025 | for Version 2 Edison Luiz Devos Barlem , Universidade Federal do Rio Grande, Rio Grande, Brazil 0 Views copyright © 2025 Barlem E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for submitting the manuscript entitled "Validation of the Thai version of the World Health Organization’s Quality of Life Scale (WHOQOL-BREF-THAI) among Thai nursing students in northeast Thailand: A multi-centre study." After a thorough review, we acknowledge that this study presents a relevant and timely contribution by seeking to validate a culturally adapted version of the WHOQOL-BREF among nursing students—a population often exposed to stressors that directly impact their quality of life and academic performance. The methodological design is robust, and the sample size is adequate, with proper use of statistical techniques for both exploratory and confirmatory factor analyses. Nevertheless, we identified areas that require improvement, which are detailed below. To begin with, the title is well formulated and accurately reflects the study's scope. The abstract follows the conventional structure, though it remains overly synthetic in some essential areas. We recommend expanding the methods section in the abstract and including core statistical indicators, such as model fit values and key numerical findings. It is also important to mention the psychometric tools applied (EFA, CFA, AVE, CR) to ensure clearer communication of the results. The objective is pertinent and aligns with the justification provided, but we suggest reformulating it to ensure greater clarity and methodological specificity. For instance: “To assess the psychometric properties (construct validity, internal consistency, and convergent/discriminant validity) of the Thai version of the WHOQOL-BREF among nursing students in northeastern Thailand.” This revised version more accurately reflects the methodological nature of the study. The introduction provides a solid overview of the quality of life (QoL) concept, based on recent and relevant literature. However, we encourage a deeper conceptual discussion, especially drawing on classical WHO documents and leading authors on QoL assessments in educational and cultural contexts. Additionally, although the manuscript refers to cultural variability in the WHOQOL-BREF’s factor structure, this discussion would benefit from a more critical perspective, addressing the theoretical and methodological implications of cross-cultural validity. The methods section is clearly articulated and well developed, detailing the sampling procedures, inclusion and exclusion criteria, and appropriate statistical approaches. The decision to split the sample for EFA and CFA is methodologically sound. However, it is important to specify the statistical software used, justify the choice of WLSMV estimation in relation to the ordinal nature of the data, and discuss the criteria used to exclude cross-loading items. We also suggest explaining whether normality tests were performed and reflecting on potential bias from using self-administered questionnaires. The results are clearly presented, with relevant tables and statistical indicators. The factor analysis is consistent with the objectives, and the fit indices support the validity of the four-domain model. Nevertheless, we recommend that the authors explore potential associations between sociodemographic variables and QoL domains using additional analyses (e.g., ANOVA or multiple regression). Such analysis would provide further insight into determinants of QoL among nursing students. The discussion is well structured and draws appropriate comparisons with previous studies. However, it lacks critical reflection on the study’s own limitations—such as the cross-sectional design, potential social desirability bias, and the lack of test-retest reliability assessment. It would be valuable to expand on the practical implications of the validated instrument for nursing education management, institutional screening, and mental health support programs. We suggest including this in a dedicated subsection. The conclusions are consistent with the findings but could be strengthened by proposing the use of the instrument in intervention contexts, longitudinal evaluations, and institutional policies for student support. Emphasizing the practical contributions of the study would enhance its scientific and social impact. The references are mostly recent and relevant. However, we recommend including additional sources such as systematic reviews and international guidelines on cross-cultural validation of psychometric instruments. In summary, this is a relevant study with the potential to contribute meaningfully to research on mental health and nursing education. Nonetheless, to fully meet the standards of high-impact international journals, we recommend a major revision , incorporating the suggestions detailed above. We remain available to re-evaluate the manuscript should the authors decide to submit a revised version. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Nursing I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 09 Aug 2025 Ueamporn Summart, Faculty of Nursing, Roi Et Rajabhat University, Kho Kaew Subdistrict, Selaphum District, 45120, Thailand Thank you for all of your suggestions and comments for improving our manuscripts. I attempted to edit and revise our manuscripts followed your suggestions; however, our study have some limitation about the data collection, so we cannot explore potential associations between sociodemographic variables and QoL domains using additional analyses (e.g., ANOVA or multiple regression). Such analysis would provide further insight into determinants of QoL among nursing students. 1) abstracts: Thank you for your suggestions. We edited our abstract following your comments, including objective, methods, and results. 2) We specify the statistical software used and the normality test for supporting our statistical analysis. 3) We also added the systematic reviews of WHOQOL questionnaires and discussed with the community for supporting our psychometric properties of this measurement. 4) We added our limitations due to the cross-sectional design and lack of test-retest into the limitation sections. 5) We revised our conclusions with suggestions for longitudinal studies for better outcomes. Finally, we appreciated your suggestions for improving our manuscripts. Please consider our revised manuscript. Best regards, Ueamporn Summart View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Barlem ELD. Peer Review Report For: Validation of the Thai version of the World Health Organization’s Quality of Life Scale (WHOQOL-BREF-THAI) among Thai nursing students in northeast Thailand: A multi-centre study [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :241 ( https://doi.org/10.5256/f1000research.182565.r395384) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-241/v2#referee-response-395384 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 do Carmo Cruz Robazzi M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 14 Jun 2025 | for Version 2 Maria Lúcia do Carmo Cruz Robazzi , University of São Paulo, São Paulo, Brazil 0 Views copyright © 2025 do Carmo Cruz Robazzi M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I have already reviewed the manuscript and the recent changes, and I consider the article approved . The revisions made are appropriate, and I see no need for further modifications or to change my previous review status. Competing Interests Nursing and Occupation Health Reviewer Expertise Nursing; Ocuupational Health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) do Carmo Cruz Robazzi ML. Peer Review Report For: Validation of the Thai version of the World Health Organization’s Quality of Life Scale (WHOQOL-BREF-THAI) among Thai nursing students in northeast Thailand: A multi-centre study [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :241 ( https://doi.org/10.5256/f1000research.182565.r386867) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-241/v2#referee-response-386867 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 do Carmo Cruz Robazzi M et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 21 May 2025 | for Version 1 Maria Lúcia do Carmo Cruz Robazzi , University of São Paulo, São Paulo, Brazil Fabio de Souza Terra , School of Nursing, Federal University of Alfenas, Alfenas, Minas Gerais, Brazil 0 Views copyright © 2025 do Carmo Cruz Robazzi M et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (2) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This study, which validated the Thai version of the WHOQOL-BREF in a robust sample of 3,570 nursing students from northeastern Thailand, presents relevant results regarding the psychometric properties of the instrument in this specific population. The analysis identified a four-domain structure with 24 items, demonstrating good internal consistency (alpha > 0.70) and convergent validity (AVE > 0.50). The authors pertinently conclude that the WHOQOL-BREF-THAI is a valid and reliable tool for assessing the quality of life of these students, with potential application in nursing research and education. Considering the validation context – nursing students in all four years of undergraduate study in northeastern Thailand – the study proves to be interesting and necessary. The cited literature is relevant to the topic. However, it is observed that only 32.55% of the 43 references presented are from the last five years. It is therefore suggested that the authors seek to include a greater number of updated references, aiming to reach at least 50% of more recent citations. Although subsequent and suggested studies in this review do not focus on the validation of the WHOQOL-BREF in nursing students or analyze other instruments, some may enrich the discussion of the present work. The following references, for example, could be considered in the Introduction, Method, or Discussion to increase the percentage of recent studies: ( refer 1, 2 , 3 and 4 ) Summary: The objective presented in the summary is consistent with that of the body of the text. The summary is clear, and the conclusion adequately responds to the proposed objective. Introduction: Well-presented and clear, the introduction directs the reader to the gap in the literature regarding the psychometric properties of the WHOQOL-BREF in Thai nursing students, clearly establishing the main objective of the study. It is important to note that the authors used the WHO's concept of quality of life (QOL), the organizing principle of the original WHOQOL, which in its construction used this same concept of QOL as a theoretical framework. Method: The study design is detailed enough to allow for replication by other researchers. However, as it is a validation study, it is suggested that it also be characterized as a “methodological study.” The statistical analysis employed is appropriate, and the sample of 3,570 Thai nursing students was adequately divided for the exploratory (n=2000) and confirmatory (n=1570) analyses. Results: The results are presented clearly through five tables and one figure, highlighting the main findings that address the study's objective, which is expected for research of this nature. Discussion: The discussion is adequate and based on relevant literature, although the inclusion of more recent studies could enrich it. Strengths and Limitations: Adequately presented. However, if the authors aimed to study only nursing students, we do not understand this element as a limitation; other authors and new studies can carry out the validation process with different students. Conclusions: The conclusions are consistent with the objective and based on the results. Data Availability: The data is accessible in the Figshare repository. In summary, this study significantly contributes to the understanding of the psychometric properties of the WHOQOL-BREF in Thai nursing students. The suggested updating of references may further strengthen the theoretical foundation and the discussion of the results. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes References 1. Putri GP, Inggrini I, Tanjung NAD, Pakpahan M, et al.: The Lifestyle and Quality of Life Among Nursing Students. J Holist Nurs . 2025; 43 (1): 18-25 PubMed Abstract | Publisher Full Text 2. Galgam FA, Abdalla A, Shahin M, Yousif M, et al.: Assessing the quality of life among African medical and health science students using the WHOQOL-BREF tool. PeerJ . 2025; 13 : e18809 PubMed Abstract | Publisher Full Text 3. Hall LA, Lee Ridner S, Crawford TN: The Psychometric Properties of the World Health Organization Quality of Life-BREF Questionnaire in College Students. J Nurs Meas . 2024; 32 (2): 256-266 PubMed Abstract | Publisher Full Text 4. Santin Júnior LJ, Martins BG, Campos JADB, Vazquez ACS, et al.: Psychometric properties of the Burnout Assessment Tool - General version in nursing workers. Rev Lat Am Enfermagem . 2025; 33 : e4425 PubMed Abstract | Publisher Full Text Competing Interests Nursing and Occupation Health Reviewer Expertise Nursing; Ocuupational Health We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above. reply Respond to this report Responses (2) Author Response 09 Aug 2025 Ueamporn Summart, Faculty of Nursing, Roi Et Rajabhat University, Kho Kaew Subdistrict, Selaphum District, 45120, Thailand Thank you for all of your suggestions. After we considered all of your suggestions, we agreed with your opinions to edit and revise our manuscript as follows: 1) We edited our citation following your suggestion in the introduction part and discussion part. 2) We edited our study design into "a methodological study." Please see our revised manuscript. 3) Limitation: Thanks for your suggestions. We deleted this statement from this part and added another limitation regarding data being collected at a single point in time. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Author Response 09 Aug 2025 Ueamporn Summart, Faculty of Nursing, Roi Et Rajabhat University, Kho Kaew Subdistrict, Selaphum District, 45120, Thailand I would like to express my gratitude for your diligent efforts to comment on and suggestions for improving our manuscript. We appreciated all of this and attempted to edit this manuscript following your comments. If you have any comments, we do not hesitate to edit our manuscripts following your comments and send them back to your process as fast as possible. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern do Carmo Cruz Robazzi ML and de Souza Terra F. Peer Review Report For: Validation of the Thai version of the World Health Organization’s Quality of Life Scale (WHOQOL-BREF-THAI) among Thai nursing students in northeast Thailand: A multi-centre study [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :241 ( https://doi.org/10.5256/f1000research.177256.r375812) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-241/v1#referee-response-375812 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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