Original scientific paper
Original scientific paper
, Mitrichka Dzambazovska Stardelova² , Slavica Novacevska² , Visar Ganiu³ 
: Abstract
Designed to assess health-related quality of life among young populations, the Albanian version of the KIDSCREEN-27 ensures dependable evaluations in culturally diverse environments. The aim of the study was to examine the suitability of the instrument in evaluating various dimensions of health-related quality of life. The research included 143 eleven-year-old students from public primary schools in Gjilan, Republic of Kosovo.The study used advanced and robust statistical methods, such as Exploratory and Confirmatory Factor Analysis (EFA and CFA) to assess the structure of the construct, along with measuring internal consistency through Cronbach’s coefficient, while the use of T-scores enabled cross-cultural comparisons, relying on appropriate statistical tools such as SPSS and Jamovi for psychometric assessment. Statistical analysis showed that the six-factor adaptation of the KIDSCREEN-27 provides a better fit for the data from 11-year-old children in Kosovo compared to the original five-factor framework. This updated model exhibited strong fit indicators (CFI = 0.98; RMSEA = 0.075) alongside a more distinct conceptual organization. Additionally, the internal reliability was satisfactory (α = 0.71–0.82), with minimal presence of ceiling or floor effects.Factor loadings were higher and more stable in the six-factor model. Several significant gender differences were identified, with boys scoring higher in certain dimensions. Overall, the instrument proves to be suitable and valid for use within the cultural and social context Republik of Kosovo.
Keywords:
Quality of Life; Gender Differences; Cultural and Social Context; KIDSCREEN-27; Children; Kosovo
Recently, interest has grown in assessing children’s health-related quality of life as overall well-being, not just absence of illness. Various researchers have emphasized that children’s health should not be reduced to the assessment of their physical condition alone. According to (Ravens-Sieberer et al., 2007; Michalos, 2014; Befus et al., 2023), children’s well-being is not only related to the physical aspect of health, but also includes emotional, social and behavioral dimensions. The work of (Power et al., 2019; Solans et al., 2008; Taylor et al., 2008; Higginson & Carr, 2001; Eiser & Morse, 2001; Cieza & Stucki, 2005), have contributed significantly to the development of these tools and their adaptation to different cultural and social contexts.
According to Duncan (1984) and DeVellis & Thorpe (2021), measurement accuracy is a fundamental pillar of scientific research, especially when it comes to assessing health-related quality of life during childhood. In this regard, several general instruments adapted for children have been developed and are widely integrated into clinical practice, public health programs and health policy evaluations (Solans et al., 2008; Verstraete et al., 2020). Some of the most popular tools include the YQOL-R (Edwards et al., 2002; Patrick et al., 2002), the CHQ (Landgraf et al., 1998) and the KIDSCREEN questionnaire group (KIDSCREEN Group Europe, 2006).
KIDSCREEN-27 is a concise yet thorough tool developed to evaluate the health-related quality of life among children and adolescents aged 8 to 18. The instrument focuses on five main aspects: physical and emotional well-being, degree of autonomy and family ties, peer support, and experience in the school
environment (Budler et al., 2022). This questionnaire has been tested and validated in many languages and cultures, and has found widespread use in both education and health interventions (Ravens-Sieberer et al., 2001, 2005, 2006)
This KIDSCREEN-27 form has been evaluated for its practical importance, as it helps reduce test taker monotony (Khan et al., 2017; Ravens-Sieberer et al., 2010; Locker & Allen, 2002; Huebner et al., 2004). However, reducing the number of items in a measurement instrument requires careful psychometric evaluation, to ensure that the theoretical validity and inclusion of all key dimensions of the concept are not compromised (Pollak et al., 2006; Muehlan, 2010)
International studies have shown that the factor structure of the KIDSCREEN-27 instrument can vary depending on the cultural context and sample characteristics. For this reason, some research has suggested alternative models with more than five factors, in order to more accurately represent the latent construct of data in different populations (Jafari et al., 2012; Cilar Budler et al., 2022; Power et al., 2019; Li et al., 2024; Shannon et al., 2017; Ravens-Sieberer et al., 2014).
This study aims to evaluate the psychometric properties of the Albanian version of KIDSCREEN-27 among 11-year-old children in Kosovo, a group that has not been previously examined in validation studies.Using exploratory and confirmatory factor analyses, the study examines model fit, internal consistency, ceiling and floor effects, as well as gender differences.
Participants
The study involved 11-year-old boys and girls attending public primary schools across Kosovo. This age group was chosen due to its developmental importance and the need for early assessment of health-related quality of life (HRQoL).The study included 11-year-old male and female children who were regular students in public primary schools across Kosovo. The selection of participants at this age was motivated by the specific developmental characteristics of this stage and the need to undertake early assessments of HRQoL, which may inform preventive and supportive interventions.
The study’s final sample consisted of 143 pupils 82 boys and 61 girls recruited from various public primary schools in Gjilan, the capital of Kosovo. A non-probability convenience sampling method was used, and participants were included based on the following criteria: (1) parental or guardian written consent, (2) consistent school attendance, and (3) adequate cognitive capacity to comprehend and independently complete the questionnaire.
Minor children involved in the research and their legal guardians were clearly and fully informed about the purpose of the research, the voluntary nature of participation, the strict preservation of data confidentiality, and the ethical principles of the Declaration of Helsinki were respected, protecting the dignity and well-being of children participating in the research.
Measurement Instrument
The KIDSCREEN-27 questionnaire was used to assess health-related quality of life (HRQoL), where this instrument assesses five main domains of children’s quality of life – covering physical and mental health, family relationships, peer support and school experience – through 27 questions (Ravens-Sieberer et al., 2007). Ky instrument është krijuar, strukturuar, testuar dhe vërtetuar si i saktë. Responses are given on a five-point Likert scale, reflecting either frequency or intensity of experiences during the past week.
Data Analysis
For each of the five dimensions included in the KIDSCREEN-27 instrument, arithmetic means and standard deviations were calculated in order to describe the overall distribution of the results. The data were then converted into standardized T-scores following the KIDSCREEN methodological guidelines, which allows for direct comparison of these results with those of international studies and supports cross-cultural assessments of child well-being. In the evaluation if 15% of the participants scored the maximum or minimum possible score, to identify limitations in the distribution of the results.
Internal consistency of the scales was evaluated using Cronbach’s alpha coefficient, with values above
0.60 considered acceptable, particularly for scales with fewer items. To examine gender differences, one-way analyses of variance (ANOVA) were conducted for both the original and modified model dimensions, applying a significance level of p < 0.05 and interpreting effect size using partial eta squared (η²).
For exploratory analysis of factors (EFA) I use the Principal Axis Factoring method, together with the rotational oblique Promax, which allows the connection between factors an approach that is suitable for the psychological construct of interrelationships. The goodness of fit of this analysis was assessed through the Kaiser-Meyer-Olkin (KMO) index and Bartlett’s test of sphericity, which indicated favorable conditions for factor analysis.
Factor analysis was performed in two stages. Initially, Kaiser’s criterion (characteristic value greater than 1) was applied, which suggested the existence of seven factors. In the second step, the extraction of six factors was predicted, in accordance with the theoretical basis and the data of the confirmatory analysis. Factor loadings with values ≥ 0.30 were considered significant for interpretation.
All statistical analyses were conducted using IBM SPSS Statistics (v28). Confirmatory Factor Analysis (CFA) was performed in Jamovi (v2.4.8) using the SEM module (semLavaan) with DWLS estimation, appropriate for ordinal and categorical data.
Initially, the theoretical model with five factors was tested, which matches the original structure of KIDSCREEN-27, while an alternative model with six factors was then evaluated, based on the findings of the exploratory analysis.
Due to the sensitivity of the χ² test to sample size, model fit evaluation focused primarily on the CFI and TLI indicators. Values above 0.95 for these indices and an RMSEA ≤ 0.06 are considered indicative of a good model fit to the data. The combined analytical approach used in this study enabled an in-depth and reliable examination of the psychometric structure of the KIDSCREEN-27 instrument, assessing its suitability for 11-year-old children in the Kosovo context. The parallel use of exploratory and confirmatory analysis strengthens the interpretation of the results and provides a solid basis for decision-making about future use of the scale in similar settings.
Results Descriptive data for the original five-factor and modified six-factor models of the KIDSCREEN-27 instrument are presented in Table 1. In the five-factor model, Cronbach’s alpha reliability coefficients ranged between 0.75 and 0.82, while the standardized T-scores were close to the normative mean (M = 50; SD = 10), reflecting good internal consistency and adequate normalization of the scores. Ceiling and floor effects were very low (<1.5%), indicating good sensitivity of the measurement tools. In the case of the six-factor model, alpha values ranged from 0.71 to 0.79, with raw score means ranging from 8.94 to 17.75 and minimal ceiling effects (up to 2.8%), indicating acceptable psychometric stability and stable distribution of responses.
Table 1. Descriptive statistics: Raw and T-scale means, standard deviations, internal consistency (Cronbach’s α), and floor/ceiling effects
Screenshot 2026-02-03 at 22.49.27
Note: Raw M = Mean of raw scores, Raw SD = Standard deviation of raw scores, T M = Mean of T-scores (standardized to M = 50, SD = 10), T SD = Standard deviation of T-scores, α = Cronbach’s alpha (internal consistency), n/a = Not applicable for the revised structure
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