The Development of the Pictorial Thai Quality of Life

J Med Assoc Thai Vol. 88 No. 11 2005 1605

Correspondence to : Phattharayuttawat S, Department ofPsychiatry, Faculty of Medicine, Siriraj Hospital, MahidolUniversity, Bangkok 10700, Thailand. Phone: 0-2419-7000ext 4277, Fax: 0-2411-3430

J Med Assoc Thai 2005; 88 (11): 1605-18Full text. e-Journal: http://www.medassocthai.org/journal

The Development of the Pictorial Thai Quality of Life�

Sucheera Phattharayuttawat PhD*,Thienchai Ngamthipwatthana MD*, Buncha Pitiyawaranun MEd**

� This research was supported by a grant from the Faculty of Medicine 2004,Siriraj Hospital, Mahidol University

* Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University** Medical Technology, Faculty of Medicine, Siriraj Hospital, Mahidol University

Background: “Quality of life” has become a main focus of interest in medicine. The Pictorial Thai Quality ofLife (PTQL) was developed in order to measure the Thai mental illness both in a clinical setting and community.Objectives: The purpose of this study was to develop the Pictorial Thai Quality of Life (PTQL), having ad-equate and sufficient construct validity, discriminant power, concurrent validity, and reliability.Material and Method: To develop the Pictorial Thai Quality of Life Test, two samples groups were used in thepresent study: (1) pilot study samples: 30 samples and (2) survey samples were 672 samples consisting ofnormal, and psychiatric patients. The developing tests items were collected from a review of the literature inwhich all the items were based on the WHO definition of Quality of Life. Then, experts judgment by the Delphitechnique was used in the first stage. After that a pilot study was used to evaluate the testing administration,and wording of the tests items. The final stage was collected data from the survey samples.Results: The results of the present study showed that the final test was composed 25 items. The constructvalidity of this test consists of six domains: Physical, Cognitive, Affective, Social Function, Economic and Self-Esteem. All the PTQL items have sufficient discriminant power. It was found to be statistically significantdifferent at the.001 level between those people with mental disorders and normal people. There was a highlevel of concurrent validity association with WHOQOL-BREF, Pearson correlation coefficient and Area underROC curve were 0.92 and 0.97 respectively. The reliability coefficients for the Alpha coefficients of the PTQLtotal test was 0.88. The values of the six scales were from 0.81 to 0.91.Conclusions: The present study was directed at developing an effective psychometric properties pictorialquality of life questionnaire. The result will be a more direct and meaningful application of an instrument todetect the mental health illness poor quality of life in Thai communities.

Keywords: Development, Pictorial Thai quality of life

Psychiatric patients can devastate the livesof people who suffer from it and the lives of theirfamilies. People with mental illness suffer distress, dis-ability, reduced productivity and lowered quality oflife(1). The development of quality of life measures foruse in psychiatric disorders has not progressed at thepace it has in other clinical disciplines(2). Quality of lifeinstruments are not designed to guide diagnosis, but

are intended as measures of patient-assessed healthand well-being, and are constructed to include issuesof importance to patients. A number of instrumentsexist to measure health status and health-relatedquality of life. For example, the SF-36 health surveyquestionnaire(3), Nottingham Health Profile(4) theSickness Impact Profile(5), the Oregon Health-RelatedQuality of Life Questionnaire(6), and the Quality ofLife Self-Report-100(7), all general measures of healthstatus that can be used to assess functioning and well-being in any patient group. However, such genericmeasures can often overlook the quality of life concerns

1606 J Med Assoc Thai Vol. 88 No. 11 2005

of specific patient groups. Although there are anumber of measures available for the assessment ofquality of life, these measures cannot be consideredappropriate for evaluating interventions for the follow-ing reasons:

(a) some measures are too lengthy (over 100items) for use in psychiatric patients: e.g. the OregonHealth Related Quality of Life Questionnaire(6), andthe Quality of Life Self-Report-100(7);

(b) some need to be completed by a psychia-trist or other trained interviewers, whereas a measureof quality of life is dependent on subjective self-report:e.g. the Satisfaction with Life Domains Scale(8), andManchester Short Assessment of Quality of Life(9);

(c) some measures take a broad view ofQuality of Life, developed for the assessment of com-

munity programmes, and were, therefore, consideredto be unlikely to be sensitive to quality of life changesresulting from clinical changes as measured in clinicaltrials: e.g. the Community Adjustment Form(10).

The present study was directed to develop arobust quality of life instrument specific to psychiatricpatients, based on the WHO quality of life definition(11)

in pictorial form. The result will be a more direct andmeaningful application of an instrument to measurethe quality of life of mental health illness in the Thaicommunity.

Conceptual FrameworkDue to the literature reviewed, the conceptual

framework of the present research project was set asFig. 1.

Fig. 1 Conceptual of the Pictorial Thai Quality of Life (PTQL)


Material and MethodMethod of Recruitment of Study Population

With the approval of the ethics committee,a total 672 subjects were systematically randomizedfrom the samples target.

Source of Study PopulationSubjects in the present study were volun-

teers from- inpatient and outpatient of the Department

of Psychiatry, Siriraj Hospital.- normal people from secondary school,

college, university, working people, and aging peoplefrom an aging club.

Inclusion Criteria••••• Psychiatric patientsThe inclusive criterion were determined as

follows:1. Age between 12 to above 60 years2. Both male and female3. Volunteered to join the project4. Able to communicateThe exclusive criteria1. People who had a disturbed condition2. People who had a Mental Retardation

condition.

••••• Normal peopleThe inclusive criterion were determined as

follows:1. Age between 12 to above 60 years2. Both male and female3. People who do not have a history of mental

illness.The exclusive criteria

People who had a mental retardation con-dition.

Sample sizeSurvey samples group 1: Psychiatric patients

of Siriraj Hospital were calculated by the formula(13)

NZ2P (1 - P)np =

NE2 + Z2P(1 - P)np = Sample sizeN = size of target population of the present

research (the psychiatric outpatients atSiriraj Hospital in one year) was 13,000cases

{(50 x 5) x 52 = 13,000}{(psychiatric cases / day x 5days) x 52)}

Z = value of normal curve at area under thenormal curve range (α/2);The present research determinedα = .05; Z = 1.96

P = proportion of population who have amental problem, this research determinep = .30(12)

E = error size, this research determinedE = .05 (13,000)(1.96)2 (.3)(.7)

np =(13,000)(.05)2 + (1.96)2(.3)(.7)

= 314.878 ≈ 315Survey samples group 2: Normal peopleThe normal people group was 315 subjectsThe sample was stratified on the variables of

sex, age, occupation, and education. So the total samplesize of the present research was extended to 672.

Study ProceduresTo develop the Pictorial Thai Quality of Life

tests, two groups of samples were used in the presentstudy: (1) pilot study samples, and (2) survey samples.All participation samples in the present study are thevoluntary staff and responses from individual partici-pants will be held in confidence.

The procedure of developing the PictorialThai Quality of Life tests divided into two phases:preliminary development of the sources of the testitems and field collecting data.

The preliminary development of the sourcesof the test items:

The Pictorial Thai Quality of Life was devel-oped from designs to a literature review in which allthe items were based on the WHO definition of qualityof life. This test consists of six domains: (1) Physical,(2) Cognitive, (3) Affective, (4) Social Function, (5) Eco-nomic, and (6) Self-Esteem.

For the preliminary review, it was composedof 35 items and the frequency with which they arereportedly experienced by the statement: “Here is a listof pictures that describe some of the ways people feelat different times. How often do you feel each of theseways? “Never?” “Sometimes?” “Often?” The 28 itemswere grouped in six categories. Scale construction forthe PTQL, The authors calculated the scale accordingto two methods; experts judgment by Delphi techniqueand by Factor analysis.


In the pilot study, to test the testing adminis-tration and the picture test items, it was found thatsome pictures were not clear. After the pilot study, 3 ofthe 28 items were excluded.

The final stage was to collect data from thesurvey samples using the Pictorial Thai Quality ofLife 31 item-form. The 31 items were analyzed by factoranalysis. A subsequent principal components analysisperformed by the varimax rotation revealed six factors.The factor loading criteria was 0.40. Of the 28 items, 3were excluded. Then exploratory factor analysis of thetest items were analyzed. Remaining items (25 from 28)to be used for assessing quality of life of the normaland psychiatric patients. The discriminant power ofthe test was analyzed by comparing the mean of the27% of the normal and psychiatric group with inde-pendent t-test. All the test items were found to besignificantly different at p < .001. Concurrent validitywas assessed by Pearson Product Moment betweenthe PTQL and WHOQOL-BREF raw score. Internalreliability was assessed using Cronbach’s Alpha.

Fig. 2 shows the summarized form of the studyprocedure.

InstrumentsThe PTQL composes of 25 item-form (see

appendix) and the WHOQOL-BREF(14).

Statistical analysisFactor analysis was performed to evaluate an

image factoring method with varimax rotation used forthe construct validity(15,16). Discriminant analysis wasassessed by comparing means raw score on each capa-city subtest between the mental illness and normalpeople by t-test(17). Concurrent validity was assessedby Pearson Product Moment between the PTQL andWHOQOL-BREF raw score. Internal reliability wasassessed using Cronbach’s Alpha (∝)(17).

ResultsCharacteristics of the Samples

The subjects comprised 672 samples from twomain groups: 336 normal and 336 psychiatric patients,including 306 males and 366 females aged between 12to 78 years. The samples were distributed by sex, age,occupation, income, and education.

Construct ValidityIn the pilot study, to test the testing adminis-

tration and wording of the test items, it was found thatsome items were not clear. After the pilot study, 3 of the

28 items were excluded because the picture was notclear.

The final stage was the collection of data fromthe survey samples using the PTQL 25 item-form.

A principal components analysis was carriedout on results from the 25 pictorial questionnairesobtained in stage 1. Six factors with item-loadings> 0.4(15,16) were identified, which appeared to charac-terize six underlying constructs: Physical, Cognitive,Affective, Social Function, Economic, and Self-EsteemDomain. These six factors, which accounted for 67.59%of the variance, were then subjected to varimax rota-tion. Items loading < 0.4 on any factor were removed atthis stage. It was assumed that items loading > 0.4 oneach factor constituted a scale. Internal reliability wasassessed on the items constituting each scale. Itemswere removed from each of the scales if they increasedthe ∝ coefficient. When these factors were subjectedto a varimax rotation, it became easier to conceptualizethe factors. Exploratory factor analysis of the PTQLitems which initially included 25 items and was extractedinto 6 factors. The process of factor analysis is shownin Tables 1-4.

Discriminance ValidityRemaining items (25 from 28) to be used for

assessing quality of life of the normal and psychiatricpatients. The discriminant power of the PTQL wasanalyzed by comparing the mean of the 27% of thenormal and psychiatric group with independent t-test.

Table 2. Factor loading of each item used for assessingthe PTQL

PTQL factor

1. Physical2. Cognitive3. Affective4. Social function5. Economic6. Self-esteem

Factor loading

0.61440.41290.52180.44160.50120.4178

Table 1. The Varimax rotation of first factors accord-ing for using factor of 0.40 criteria

Questions comprisingitem with less than 0.40

12, 13, 17

Questions comprising item with more than 0.40

1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 14,15, 16, 18, 19, 20, 21, 22, 23,24, 25, 26


Fig. 2 Summarized of the study procedure


All PTQL items were found to be significantly differentat p < .001. That means the PTQL has sufficient powerto discriminate between those with mental illness andnormal people (Table 5).

Concurrent ValidityThe strong associations between the PTQL

and the WHOQOL-BREF, measured as correlations forcontinuous measures and as areas under the receiveroperating characteristic (ROC) curves for the dichoto-mous measures, suggest that the PTQL has capturedthe essence of the instruments from which it wasderived (p < 0.001) (Table 6).

ReliabilityTable 7 shows the correlations of items with

their scale totals, and the internal consistency reliabi-lity of the scales (that is, the extent to which items ina scale reflect a single underlying dimension). TheAlpha coefficients were high for PTQL total test score,which estimate Alpha of 0.88. In the remaining sixsub-scales, Cronbach’s Alpha ranged from 0.81 (SocialFunction) to 0.93 (Physical)

DiscussionMeasuring Pictorial Thai Quality of Life

For the scale construction of the PictorialThai Quality of Life (PTQL), The authors calculatedthe scale according to two methods: for the expertopinion by Delphi technique and factor analysis. PTQLhas become an established component of healthoutcome assessment. It puts people with both normaland mental illness. PTQL is defined as “a multidimen-tional concept based on rater self-report about theirquality of life which composes of six domain; Physical,Cognitive, Affective, Social Function, Economic, andSelf-Esteem. There is an untested assumption thatpeople with severe mental illness like schizophreniacannot reliably complete self-report questionnaires,

Table 4. Varimax rotation of six factors accounting for67.59% of variance

Factor

123456

Name of Factor

PhysicalCognitiveAffectiveSocial FunctionEconomicSelf-Esteem

Item no.

1.1, 1.2, 1.3, 1.4, 1.52.1, 2.2, 2.33.1, 3.2, 3.3, 3.4, 3.54.1, 4.2, 4.3, 4.45.1,5.26.1,6.2,6.3,6.4,6.5

*** p < .001

Table 5. Mean, Standard deviation, and t-test betweenthe high and low groups

PTQL Item

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

NormalMean SD

2.47 .51 2.50 .57 2.83 .38 2.93 .25 2.90 .31 2.53 .68 2.63 .61 2.67 .64 2.33 .66 2.33 .61 2.60 .62 2.43 .68 2.67 .55 2.70 .47 2.47 .63 2.67 .48 2.80 .41 2.41 .57 2.47 .63 2.30 .60 2.27 .64 2.55 .63 2.47 .63 2.53 .64 2.80 .43 2.67 .53

PsychiatricMean SD

1.70 .65 1.81 .71 1.91 .76 1.83 .70 1.70 .71 1.87 .73 1.80 .71 1.67 .71 1.50 .57 1.77 .61 1.67 .71 1.83 .70 2.00 .79 1.90 .76 1.67 .71 1.80 .71 1.97 .81 1.83 .75 1.87 .68 1.70 .70 1.67 .71 1.67 .71 1.67 .71 1.61 .46 1.97 .80 1.77 .63

t-test

5.09 4.19 6.03 8.10 8.59 3.66 4.84 3.44 5.22 3.91 5.41 3.33 3.81 7.58 4.92 4.62 5.52 5.04 3.69 3.54 3.57 3.44 5.00 3.84 5.52 4.67

p-value

.000

.000

.000

.000

.000

.001

.000

.001

.000

.000

.000

.001

.000

.000

.000

.000

.000

.000

.000

.001

.001

.001

.000

.000

.000

.000

Table 6. Pearson correlation coefficient, Area underROC curve of PTQL

Pearson correlation coefficient 0.92Area under ROC curve 0.97 (99%CI 0.92-0.99)

Table 3. Unrotated principal axes analyzed of thePTQL

Factor No.

123456

Eigenvalue

31.911515.633611.434310.66668.76545.4498

Name of Factor

PhysicalCognitiveAffectiveSocial FunctionEconomicSelf-Esteem


but there is growing empirical support for the use ofshort self-administered PTQL measure can yield resultsconsistent with in-depth interviews. Furthermore, ifpatients can be honest about their PTQL concernswithout the pressure of a face-to-face interview, self-administered assessments may be more valid thaninterview assessments. In any event, self-report datacollection is cost-effective: research consistentlyshows that personal interviews cost 3-10 times as muchas self-report paper-and-pencil approaches(18).

ReliabilityAlpha coefficients indicate the degree to

which items exhibit a positive correlation (internalconsistency) above 0.7 is considered adequate(19).

Internal consistency reliabilities of the sixdomains incorporated in the measure have been shownto be high, and all items in each domain correlatedwell with the overall scale score. All the scales showgood internal consistency reliability(20). The authorsconsider that if the ∝ value is high, this may suggest ahigh level of items asking the same question(21).

ValidityEvidence is provided here for the validity of

the PTQL. Content validity has been addressed bydeveloping items on the basis literature or clinicalscales in this field. The content of the questionnaireaddresses experiences of importance to individuals withmental disorders. Items that were criticized by contentexperts (by Delphi technique) and respondents as be-ing meaningless or ambiguous were adapted or re-moved. Construct validity was explored by factor analy-sis. Concurrent validity was explored by correlation ofthe scale of the WHOQOL-BREF. Results suggest thatthe measures is addressing areas related(17).

Clinical usefulnessThe PTQL was developed to be a valid and

feasible questionnaire for self-completion that ad-dresses the perceptions and concerns of people withboth normal and mental illness. Its main use is likely tobe in clinical trials and the evaluation of clinical inter-ventions. Evidence is presented in the present reportto suggest that the PTQL has desirable properties interms of reliability and validity, and the authors havefound the measure to have excellent acceptability andfeasibility in practice. The patients taking part in thedevelopment of the instrument appeared to cover abroad range of reading ability, educational attainment,economic status, occupation, and location.

Further work is under way to test its psycho-metric properties in different clinical contexts and inrespondents with different levels of clinical severity.It is possible to be optimistic that the impact of thisquestionnaire on individuals’ lives can now moredirectly be considered when treatments for the diseaseare evaluated.

Clinical Implications1. The PTQL is a practical way of measuring

self-reported quality of life in people with mental illness.

Table 7. Corrected item to total correlations (ρ) andinternal reliability (Cronbach’s ∝) of domain

Domain and items

Physical Domain-Item 1-Item 2-Item 3-Item 4-Item 5

Cognitive Domain-Item 1-Item 2-Item 3

Affective Domain-Item 1-Item 2-Item 3-Item 4-Item 5

Social Function Domain-Item 1-Item 2-Item 3-Item 4

Economic Domain-Item 1-Item 2

Self-Esteem Domain-Item 1-Item 2-Item 3-Item 4-Item 5

The total test

Item to totalcorrelation, ρ

0.760.830.740.700.74

0.750.720.71

0.740.760.720.850.71

0.740.700.760.73

0.740.71

0.720.730.720.770.77

Cronbach’s ∝

0.93

0.82

0.87

0.81

0.83

0.88

0.88


2. The PTQL is intended to measure quality ofsix effects of treatments for people with mental illnessin the context of clinical trials and, by extension, in theevaluation of clinical interventions.

Limitations1. There is no “gold standard” for quality of

life in mental illness.2. Further work is underway to test the psy-

chometric properties of the PTQL in different clinicalcontexts and in respondents with different levels ofclinical severity.

AcknowledgementsThe present study was supported by the

Faculty of Medicine, Siriraj Hospital, Mahidol Univer-sity research grant, 2004. The researchers wish tothank Professor Dr. Nancy Jones for her advice onresearch methodology.

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การพฒนาแบบประเมนคณภาพชวตไทยแบบรปภาพ

สชรา ภทรายตวรรตน, เธยรชย งามทพยวฒนา, บญชา พทยวรนนท

ภมหลง: คณภาพชวตเปนตวแปรทการแพทยใหความสำคญอยางยง แบบประเมนคณภาพชวตไทยแบบรปภาพเกดขนเพอตอบสนองความสำคญดงกลาววตถประสงค: การศกษาการพฒนาแบบประเมนคณภาพชวตไทยแบบรปภาพ เพอใหไดแบบวดทมประสทธภาพในดานความตรงเชงโครงสราง อำนาจการจำแนก และความเทยงตรงวสดและวธการ: กลมตวอยางแบงออกเปน 2 กลม คอ (1) กลมศกษานำรองจำนวน 30 ราย (2) กลมตวอยางสำรวจจำนวน 672 ราย โดยกลมตวอยางทง 2 กลมประกอบดวย กลมคนปกต และกลมผปวยจตเวช เครองมอประเมนคณภาพชวตทพฒนาขนสรางตามความหมายของคณภาพชวตขององคการอนามยโลก ใหผ เช ยวชาญทำการตรวจสอบความตรงเชงเนอหาดวยเทคนคเดลฟาย ทำการศกษานำรองเพอตรวจสอบความเขาใจในการสอความหมายดวยรปภาพและขอความ หลงจากนนทำการปรบแลวพมพเปนแบบประเมนเพอนำไปใชเกบขอมลตอไปผลการศกษา: พบวาแบบประเมนคณภาพชวตททำการพฒนาขนประกอบดวย 25 ขอ ซงพบวาขอคำถามทงหมดนสามารถแยกคณภาพชวตระหวางผทมปญหาทางดานสขภาพจตและคนปกตไดอยางมนยสำคญทางสถต (p < 0.001)ความตรงเชงโครงสรางของแบบประเมนม 6 องคประกอบดงน ดานรางกาย , ความนกคด, อารมณ, สงคม, เศรษฐกจและความภาคภมใจในตนเอง แบบประเมนชดนมความตรงเชงเกณฑสมพนธกบแบบประเมนคณภาพชวตฉบบยอขององคการอนามยโลก โดยมคาสมประสทธความเทยงและ ROC ท 0.92 และ 0.97 ตามลำดบ ความเทยงตรงแบบแอลฟาของแบบวดทงฉบบเทากบ 0.88 โดยมคาความเทยงของดานยอยทง 6 ดานระหวาง 0.81 ถง 0.91สรป: แบบประเมนคณภาพชวตไทยแบบรปภาพททำการพฒนาขนมประสทธภาพดานความตรงเชงโครงสรางอำนาจจำแนกและคาความเทยง สามารถนำไปประเมนคณภาพชวตของผทมปญหาสขภาพจตในคลนกและคนทวไปในชมชนไทย


Appendixภาคผนวก

แบบประเมนคณภาพชวตไทยแบบรปภาพ

คำแนะนำ: ขอความและภาพตอไปน เปนสงทคนทวไปเคยประสบในชวตประจำวน ซงแตละทานจะม

ประสบการณหรอความรสกทแตกตางกน ขอใหทานเลอกขอทตรงกบความรสกของทานทเปนอยในขณะน โดย

ทำเครองหมายวงกลมรอบตวเลขในระดบทตรงกบความรสกทานมากทสด คำตอบทใหไมมถกหรอผด แตเปนการ

สะทอนความเปนจรงทตรงกบตวทานมากทสด

1. ดานรางกาย (P: Physical)

1.3. นำหนกตวของฉน

มการเปลยนแปลง มการเปลยนแปลง ไมมการ

อยางมาก บางเปนครงคราว เปลยนแปลงเลย

1.4. ความผดปกตตามสวนตาง ๆ ของรางกายฉน

มปญหามาก มบางเปนครงคราว ไมมปญหาเลย

1.2. ความอยากอาหารของฉน



1.1. การนอนของฉน


2. ดานความนกคด (C: Cognitive) 3. ดานอารมณ (A: Affective)

2.3. การตดสนใจของฉน


3.1. ความวตกกงวลของฉน

มความกงวลมาก มบางเปนครงคราว ไมมความกงวลเลย

3.2. ความเหงาและความวาเหวของฉน

มมาก มบางเปนครงคราว ไมมเลย

2.2. ความจำของฉน


1.5. พละกำลงของฉน


2.1. สมาธของฉน



4. ดานการปรบตวทางสงคม (S: Social function)

ไมมความสนใจทจะทำ ทำหรอรวมกจกรรมไดบาง ยงมความสนใจหรอรวม

หรอรวมกจกรรมไดเลย เปนครงคราว กจกรรมไดเหมอนปกต

4.3. กจกรรมทางสงคมของฉน3.5. อารมณเศราของฉน


ไมสนใจเลย สนใจบางเปนครงคราว มความสนใจเหมอนเดม

4.2. ความสนใจสงรอบตวของฉน3.4. ความรสกกระวนกระวายของฉน


3.3. ความเบอหนายทอแทของฉน

มมาก มบางเปนครงคราว ไมมเลย มปญหามาก มบางเปนครงคราว ไมมปญหาเลย

4.1. การทำงานของฉน(ถาทานไมไดทำงานนอกบานในทนหมายถงการทำงานบาน)


5. ดานเศรษฐกจ (E: Economic)

6.ดานความรสกภาคภมใจในตนเอง (Self-esteem)

มนใจมาก มนใจบางเปนครงคราว ไมมความมนใจเลย

6.1. ความมนใจในการกระทำสงตาง ๆ


4.4. แรงสนบสนนทางสงคมของฉน

กงวลมาก กงวลเปนครงคราว ไมกงวลเลย

5.1. กงวลเกยวกบฐานะทางการเงน

ภาคภมใจมาก ภาคภมใจบางเปนครงคราว ไมมความภาคภมใจเลย

6.2. ความภาคภมใจในความสามารถของตนเอง

พงพอใจมาก พงพอใจบางเปนครงคราว ไมมความพงพอใจเลย

6.3. ความรสกพงพอใจกบสงทตนเองเปนอย

ไมเพยงพอ เพยงพอแตไมมเกบสะสม เพยงพอและมเกบสะสม

5.2. ฐานะทางการเงนของฉน

The Development of the Pictorial Thai Quality of Life

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