Development of the World Health Organization WHOQOL BREF Quality of Life Assessment

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1 Psychological Medicine , 1998, 28 , 551±558. Printed in the United Kingdom # 1998 Cambridge University Press Development of the World Health Organization WHOQOL-BREF Quality of Life Assessment ± " $ THE WHOQOL GROUP ABSTRACT Background. The paper reports on the development of the WHOQOL-BREF, an abbreviated version of the WHOQOL-100 quality of life assessment. Method. The WHOQOL-BREF was derived from data collected using the WHOQOL-100. It produces scores for four domains related to quality of life : physical health, psychological, social relationships and environment. It also includes one facet on overall quality of life and general health. ± 89 or above) with Results. Domain scores produced by the WHOQOL-BREF correlate highly (0 WHOQOL-100 domain scores (calculated on a four domain structure). WHOQOL-BREF domain scores demonstrated good discriminant validity, content validity, internal consistency and test±retest reliability. Conclusion. These data suggest that the WHOQOL-BREF provides a valid and reliable alternative to the assessment of domain proÆles using the WHOQOL-100. It is envisaged that the WHOQOL- BREF will be most useful in studies that require a brief assessment of quality of life, for example, in large epidemiological studies and clinical trials where quality of life is of interest. In addition, the WHOQOL-BREF may be of use to health professionals in the assessment and evaluation of treatment efficacy. position in life in the context of the culture and INTRODUCTION value systems in which they live and in relation Quality of life is deÆned by the World Health to their goals, expectations, standards and Organization Quality of Life (WHOQOL) concerns. This deÆnition reØects the view that Group as individuals' perceptions of their quality of life refers to a subjective evaluation " This paper was written by Alison Harper and Mick Power on Psychoneurological Research Institute, St Petersburg, Russia ; Dr behalf of the WHOQOL Group. R. Lucas Carrasco, University of Barcelona, Spain ; Dr Yooth # The WHOQOL Group comprises a coordinating group, Bodharamik and Mr Kitikorn Meesapya, Institute of Mental collaborating investigators in each of the Æeld centres and a panel of Health, Bangkok, Thailand ; Dr S. Skevington, University of Bath, consultants. Dr J. Orley directs the project. The work reported on United Kingdom ; Professor D. Patrick, Ms M. Martin and here was carried out in the 15 initial Æeld centres in which the Ms D. Wild, University of Washington, Seattle, USA ; and, Professor collaborating investigators were : Professor H. Herrman, Dr W. Acuda and Dr J. Mutambirwa, University of Zimbabwe, Harare, H. SchoÆeld and Ms B. Murphy, University of Melbourne, Australia ; Zimbabwe. Professor Z. Metelko, Professor S. Szabo and Mrs M. Pibernik- Data were also taken from new centres Æeld testing the WHOQOL- Okanovic, Institute of Diabetes, Endocrinology and Metabolic 100 in which collaborating investigators were : Dr S. Bonicaato, Diseases and Department of Psychology, Faculty of Philosophy, FUNDONAR, Fundacion Oncologica Argentina, Argentina ; Dr University of Zagreb, Croatia ; Dr N. Quemada and Dr A. Caria, G. Yongping, St Vincent's Hospital, Victoria, Australia ; Dr INSERM, Paris, France ; Dr S. Rajkumar and Mrs Shuba Kumar, M. Fleck, University of the State of Rio Grande do Sul, Brazil ; Madras Medical College, India ; Dr S. Saxena and Dr tsklinikum Professor M. C. Angermeyer and Dr R. Kilian, Universita $ K. Chandiramani, All India Institute of Medical Sciences, New Klinik und Poliklinik fu r Psychiatrie, Leipzig, Germany ; and Mr $ Delhi, India ; Dr M. Amir and Professor D. Bar-On, Ben-Gurion L. Kwok-fai, Queen Elizabeth Hospital, Kowloon, Hong Kong. University of the Negev, Beer-Sheva, Israel ; Dr Miyako Tazaki, In addition to the expertise provided from the centres, the project Department of Science, Science University of Tokyo and Dr Ariko has beneÆted from considerable assistance from : Dr R. Billington, Noji, Department of Community Health Nursing, St Luke's College Dr M. Bullinger, Dr A. Harper, Dr W. Kuyken, Professor M. Power of Nursing, Japan ; Professor G. van Heck and Dr J. De Vries, and Professor N. Sartorius. $ Tilburg University, The Netherlands ; Professor J. Arroyo Sucre and Address for correspondence : Professor Mick Power, Department Professor L. Picard-Ami, University of Panama, Panama ; Professor of Psychiatry, University of Edinburgh, Royal Edinburgh Hospital, M. Kabanov, Dr A. Lomachenkov and Dr G. Burkovsky, Bekhterev Edinburgh EH10 5HF. 551

2 552 The WHOQOL Group that is embedded in a cultural, social and The WHOQOL-100 encompasses 24 facets environmental context. universally regarded by all 15 Æeld centres as The WHOQOL-100 assessment was devel- important in assessing quality of life, and four oped by the WHOQOL Group in 15 inter- general questions that address overall quality of national Æeld centres, simultaneously, in an life and health. Four questions regarding each attempt to develop a quality of life assessment facet are included. Recent analysis of available that would be applicable cross-culturally. The data has shown that these 24 facets can be most appropriately grouped into four domains : development of the WHOQOL-100 has been detailed elsewhere (i.e. Orley & Kuyken, 1994 ; physical, psychological, social relationships and b environment (see Table 1). For a more detailed WHOQOL Group 1994 a , 1995 ; Szabo, 1996). , In brief, development involved the participation explanation of this analysis, the reader is referred to The WHOQOL Group (1998). All domain of all 15 Æeld centres in deciding facets of life that were important in the assessment of quality scores relating to the WHOQOL-100 in the present paper calculate domains based on a four of life, operationalizing facet deÆnitions and domain structure, although for the time being contributing items for inclusion within a pilot WHOQOL-100 data reported elsewhere will version assessment. The original pilot version of continue with the six domain structure. the WHOQOL included 236 items relating to quality of life. Fifteen Æeld centres piloted this While the WHOQOL-100 allows a detailed assessment on at least 300 people with a range of assessment of individual facets relating to quality of life, it may be too lengthy for some uses, for health problems. From these data, 100 items example in large epidemiological studies where were selected for inclusion in a revised version of quality of life is only one variable of interest. In the assessment : the WHOQOL-100 Æeld trial version. these instances, assessments will be more will- ingly incorporated into studies if they are brief, . 1991). convenient and accurate (Berwick et al WHOQOL-BREF domains of quality Table 1. The WHOQOL-BREF Field Trial Version has, of life : overall quality of life and general health therefore, been developed to look at domain level proÆles, which assess quality of life. Domain Facets incorporated within domains At a conceptual level, it was agreed by the Pain and discomfort 1 Physical health WHOQOL Group that comprehensiveness Sleep and rest ought to be maintained in any abbreviated Energy and fatigue Mobility version of the WHOQOL-100, by selecting at Activities of daily living least one question from each of the 24 facets Dependence on medicinal substances and medical aids relating to quality of life. Decisions regarding Work capacity the selection of items for the WHOQOL-BREF 2 Psychological Positive feelings were based on the following criteria. Thinking, learning, memory and ) Items selected to represent a particular i ( concentration Self-esteem domain should explain a large proportion of Bodily image and appearance variance within that domain. Negative feelings ii ( ) Items included should explain a substan- Spirituality } personal beliefs } religion tial proportion of variance within the general Personal relationships 3 Social relationships Social support facet relating to Overall Quality of Life and Sexual activity General Health perceptions. 4 Environment Freedom, physical safety and security ( ) The Ænal assessment should demonstrate iii Home environment Financial resources structural integrity in terms of conÆrmatory Health and social care : accessibility factor analysis. and quality ) The Ænal assessment should be able to iv ( Opportunities for acquiring new information and skills discriminate between identiÆed groups of Participation in and opportunities for subjects (i.e. ill versus well subjects). leisure activity } recreation Data from 20 Æeld centres situated within 18 noise } Physical environment (pollution } climate) } traffic countries were used to select items for these Transport purposes (see Table 2). One item from each of

3 Development of the WHOQOL-BREF Quality of Life Assessment 553 Centres included in development of the WHOQOL - Table 2. BREF Data from original centres Data from new centres Æeld testing the Data from original pilot Æeld testing the WHOQOL-100 WHOQOL-100 N N of the WHOQOL N Bangkok, Thailand 435 Hong Kong Bangkok, Thailand 300 856 344 464 Leipzig, Germany 527 Beer Sheva, Israel Beer Sheva, Israel Madras, India 567 Mannheim, Germany 483 Madras, India 412 300 Melbourne, Australia 350 Melbourne, Australia 421 La Plata, Argentina New Delhi, India New Delhi, India 82 Port Alegre, Brazil 82 304 300 117 Panama City, Panama Panama City, Panama Seattle, USA 300 Seattle, USA 192 411 Tilburg, The Netherlands 799 Tilburg, The Netherlands 300 96 Zagreb, Croatia Zagreb, Croatia 286 190 Tokyo, Japan Tokyo, Japan 300 Harare, Zimbabwe Harare, Zimbabwe 149 Barcelona, Spain 303 Barcelona, Spain 558 Bath, England 319 Bath, England 105 St Petersburg, Russia 300 323 Paris, France 4802 4104 Total 2369 Ø 50 % female) ; and health status (250 persons the 24 facets contained in the WHOQOL-100 with disease or impairment and 50 well persons). has been included. In addition, two items from This enabled the WHOQOL-BREF to be the Overall Quality of Life and General Health assessed in several populations. With respect to facet have been included. The WHOQOL-BREF persons with disease or impairment, this group therefore contains a total of 26 questions. included patients from a cross-section of primary-care settings, hospitals and community- METHOD care settings. Within the new Æeld centres The sample dataset, some centres collected more than the required 300 respondents, with approximately Two data sets were used to select items for 37 % of the total sample consisting of subjects inclusion in the WHOQOL-BREF. The Ærst with no health problems. included all data from 15 Æeld centres who The procedure followed by centres Æeld testing participated in the WHOQOL pilot study (see the WHOQOL-100 who had already partici- Table 2). This pilot assessment contained 236 pated in the development of the WHOQOL questions relating to quality of life. The second differed. In some of these centres, data were dataset included data from the 13 centres who collected from speciÆc populations, dependent Æeld-tested the WHOQOL-100. A further on the area of interest of the investigators dataset including data from Æve new centres, collecting the data. For example, Barcelona who had not participated at the pilot stage but collected a substantial portion of their data from had Æeld-tested the WHOQOL-100, and had patients diagnosed with schizophrenia, whereas results available, was also used to test the Madras collected data from patients with adequacy of items selected. cataracts, diabetes or cancer. By contrast, a Procedure large proportion of data from Seattle, Panama, Tilburg, Zagreb, Bath and Beer-Sheva was The procedure followed to Æeld-test the collected from healthy subjects. Hence, in this WHOQOL and the WHOQOL-100 for new dataset approximately 45 % of subjects had no centres was similar. The instrument was piloted health problems. on approximately 300 people in each Æeld centre. The sample of respondents to whom the as- Selection of items from the WHOQOL-BREF sessment was administered were adults, with As noted in the Introduction, it was agreed that ` adult ' being culturally deÆned. The sampling one item from each of the 24 facets ought to be quota applied with regard to : age (50 % 45 Ø! included in an abbreviated version of the male, Ø 45 years) ; sex (50 % Ø≠ years, 50 %

4 554 The WHOQOL Group Differences between domain scores based on WHOQOL-100. The most general question from 27 (mean either assessment ranged from 0 to 0 ± each facet (i.e. the item that correlated most ± difference Ø 0 highly with the total score, calculated as the 11). As expected from these small mean of all facets) was chosen for inclusion in differences, there were high correlations between the WHOQOL-BREF. Individual items selected domain scores based on the WHOQOL-100 and domain scores calculated using items included by this method were then examined by a panel to establish whether the items selected to represent in the WHOQOL-BREF. These correlations ± 95 (for 89 (for domain 3) to 0 ranged from 0 each domain reØected the conceptually derived ± domain 1). operationalization of facets of quality of life. That is to say, they constituted a cohesive and Internal consistency interpretable domain, with good construct val- idity. Of the 24 items selected, six were Cronbach alpha values for each of the four substituted. Three items from the environmental ± domain scores ranged from 0 66 (for domain 3) domain were substituted because they were to 0 ± 84 (for domain 1), demonstrating good highly correlated with the psychological domain. internal consistency (see Table 3). Cronbach A further three items were substituted because it alpha values for domain 3 should be read with was felt that other items within the facet could caution as they were based on three scores (i.e. better explain the concept. the personal relationships, social support and sexual activity facets), rather than the minimum Calculation of domain scores four generally recommended for assessing Domain scores for the WHOQOL-100 are internal reliability. calculated by taking the mean of all facet scores included in each domain and multiplying by a Discriminant validity factor of four. Domain scores for the The WHOQOL-100 has previously been shown WHOQOL-BREF were calculated by multi- to have excellent ability in discriminating be- plying the mean of all items included within the tween ill and well respondents (see Table 4). The domain by four. Potential scores for all domain WHOQOL-BREF was shown to be comparable scores, therefore, range from 4±20. For the to the WHOQOL-100 in discriminating between following analysis, the WHOQOL-100 is based these subject groups, with similar values and on a four domain solution, so as to be signiÆcant differences between ill and well comparable with the WHOQOL-BREF domain subjects apparent in all domains (see Table 4). scores. Statistical analysis Internal consistency of the WHOQOL - Table 3. Data analyses were carried out using SPSS BREF domains - and the WHOQOL 100 (Windows) Version 7. Internal consistency of domains was assessed using Cronbach alpha. Cronbach alpha tests t Discriminant validity was determined via Original Field New to distinguish differences between ill and well data data data subjects. Test±retest reliability was assessed Ø 2369) Ø N ( 3882) ( N Ø 4802) ( N r correlations. Contribution of using Pearson Physical health domain scores to assessing quality of life was ± WHOQOL-100 0 86 88 0 ± 87 0 ± assessed using multiple regression. ConÆrmatory ± 80 WHOQOL-BREF 0 ± 82 0 ± 84 0 factor analysis of the items included in the Psychological ± 79 0 82 WHOQOL-100 0 ± 79 0 ± WHOQOL-BREF was carried out using the ± WHOQOL-BREF 0 ± 75 0 76 77 0 ± EQS package Version 5.0 (Bentler & Wu, 1995). Social relationships 72 WHOQOL-100* 0 ± ± 0 ± 72 0 73 ± 0 ± 66 0 WHOQOL-BREF* 69 0 ± 66 RESULTS Environment Descriptive statistics WHOQOL-100 0 ± 85 0 ± 85 0 ± 85 80 WHOQOL-BREF 0 ± 80 0 ± 80 0 ± Domain scores calculated using the WHOQOL- 100 and the WHOQOL-BREF were very similar. * Only 3 items, therefore Cronbach alphas may not be reliable.

5 Development of the WHOQOL-BREF Quality of Life Assessment 555 Discriminant validity of the WHOQOL -100 - BREF Table 4. and the WHOQOL . ` well ' Comparisons ` ill ' t v tests New Field Original data data data Ø 4802) ( N Ø 3882) ( N Ø 2369) ( N tP tP tP Physical health ± 10 ± 001 39 ± 34 ± 001 25 ± 40 ± 001 WHOQOL-100 10 31 ± 20 ± 001 36 ± 40 WHOQOL-BREF 001 24 ± 20 ± 001 ± Psychological 001 13 ± 001 24 ± 00 ± 00 10 ± 30 ± 001 WHOQOL-100 ± 12 ± 30 ± 001 24 ± 00 WHOQOL-BREF 001 10 ± 60 ± 001 ± Social relationships ± 9 80 ± 001 22 ± WHOQOL-100 ± 001 7 ± 80 ± 001 00 WHOQOL-BREF 8 ± 40 ± 001 16 ± 20 ± 001 6 ± 90 ± 001 Environment 7 00 ± 001 21 ± 70 ± 001 2 ± 40 ± 02 WHOQOL-100 ± 001 ± ± 001 21 ± 10 ± 60 2 ± 80 ± 01 WHOQOL-BREF 6 tested using items in the WHOQOL-BREF. In Test±retest reliability both the dataset relating to the original pilot and Data used to assess test±retest reliability included the dataset relating to the Æeld trial of the a majority of well subjects (87 % of respon- WHOQOL-100, an acceptable Æt index (one dents) from four centres participating in the measure of which is a Comparative Fit Index of 0 ± 90 or higher) was achieved when the data Æeld trial of the WHOQOL-100. These were Ø 90), Harare ( N Ø 100), Tilburg was applied to the four domain structure (see Bath ( N N 85). In all centres, N Ø Table 5). 116) and Zagreb ( ( Ø In the dataset including new centres Æeld respondents were university students, with the testing the WHOQOL-100, the initial Com- exception of Harare, where subjects were ran- ± 87, suggesting Ø parative Fit Index (CFI) was 0 N dom samples of ill ( 50) N 50) and well ( Ø that alterations to the model were necessary. respondents. The interval between test and retest When three pairs of error variances were allowed ranged from 2±8 weeks. Correlations between to covary (i.e. pain and dependence on medi- items at time points one and two were generally 56 for item 8 (How safe do cation, pain and negative feelings, home and high, ranging from 0 ± ± physical environment) and two items were you feel in your daily life ?) to 0 84 for item 12 allowed to cross-load on other domains (i.e. (Have you enough money to meet your needs ?). safety on the global domain and medication The test±retest reliabilities for domains were negatively on the environment domain), the ± 0 66 for physical health, 0 ± 72 for psychological, 0 76 for social relationships and 0 ± 87 for en- 901 (see ± ± comparative Æt index increased to 0 Table 5). vironment. Multisample analysis was subsequently under- taken to assess whether parameter estimates ConÆrmatory factor analysis were similar across all three datasets. All parameter estimates were constrained to be ConÆrmatory factor analysis of the WHOQOL- 100 assessment, at facet level, suggested that a equal across datasets, with the exception of two of the 24 items (item 4 and item 8), as these were four domain solution may be most appropriate. This solution is shown in Fig. 1. Items relating known to cross-load on other domains in the case of the new centres dataset. In the to each domain therefore load onto that par- ticular domain. The four domains then all load multivariate model, the CFI reached 0 ± 900, onto a second order factor, representing global suggesting that the parameter estimates assessed quality of life. This four domain structure was were equivalent across all datasets.

6 556 The WHOQOL Group (Item 3) Pain Energy (Item 10) Sleep (Item 16) Mobility Physical (Item 15) Activities (Item 17) Medication (Item 4) Work (Item 18) Positive feelings (Item 5) Think (Item 7) (Item 19) Esteem Psychological Body (Item 11) Negative feelings (Item 26) (Item 6) Spirituality Relationships (Item 20) Social Support (Item 22) relationships Sex (Item 21) (Item 8) Safety (Item 23) Home (Item 12) Finances (Item 24) Services Environment Information (Item 13) Leisure (Item 14) (Item 9) Environment Transport (Item 25) ig . 1. Four domain conÆrmatory factor analysis model. F BREF domain scores made a signiÆcant con- Importance of individual domains in assessing tribution to explaining variance observed in the overall quality of life general facet relating to overall quality of life Multiple regression was used to determine the and general health, with the physical health domain contributing most highly, and the social contribution made by each domain score to explaining the observed variance in the general relationships domain making least contribution. facet from the WHOQOL-100 assessment (i.e. This suggests that all four domains should be the overall quality of life and general health taken into consideration when evaluating overall facet). As shown in Table 5, all four WHOQOL- quality of life.

7 Development of the WHOQOL-BREF Quality of Life Assessment 557 Table 5. Comparative Æt indices for the four domain model and multiple regression using general health and quality of life facet as the dependent variable and domain scores as independent variables %of overall QOL and Final equation standardized beta values* Comparative general health facet Domain 1 Dataset Domain 3 Domain 4 Æt index explained Domain 2 ± Original 62 ± 90 ± 31 0 ± 31 0 ± 16 0 ± 21 0 906 0 ± 903 68 ± 40 ± 38 0 ± 23 0 ± 17 0 ± 22 Field test 29 0 61 ± 50 ± 33 0 ± 901 0 ± 13 0 ± 20 ± New data P ! 0 ± 001. * SigniÆcant at each domain is seen as integral to an assessment DISCUSSION of quality of life (The WHOQOL Group, 1994 The WHOQOL-BREF has been shown to assess a , b ). adequately domains relevant to quality of life in It should be noted that analysis of the WHOQOL-BREF was based on taking 26 items a large number of cultures worldwide. Domain from either 100 items, or in the case of data from scores produced by the WHOQOL-BREF have 9 with the the initial pilot WHOQOL, from 236 items. been shown to correlate at around 0 ± WHOQOL-100 domain scores, which has itself While the aim is now to collect and analyse data demonstrated criterion validity. They have also from the Æeld trial version of the WHOQOL- been shown to display good discriminant val- BREF itself, we would predict similar results to idity, content validity and test±retest reliability. emerge from this procedure. In addition, further Although only one-quarter of the length of Æeld trials aim to address the responsiveness to change and concurrent validity of the the WHOQOL-100, the WHOQOL-BREF WHOQOL-BREF. incorporates good breadth and comprehensive- The WHOQOL-BREF provides an adequate ness by including items from each of the 24 alternative to the assessment of domain proÆles facets of quality of life included in the longer using the WHOQOL-100. It provides a rapid form. Despite the heterogeneity of facets in- means of scoring domain proÆles ; it does not cluded within domains, all domains display however allow assessment of the individual excellent internal consistency. facets within these domains. A balance between As with other measures shortened in such a way, the fact that the WHOQOL-BREF uses a detail and length of assessment will, therefore, subset of items included within the WHOQOL- always be important to consider when selecting 100 allows direct comparison between data between different WHOQOL assessments. It is envisaged that the WHOQOL-BREF will be collected from speciÆc populations using either of the two assessments. used primarily in circumstances where a brief The WHOQOL-BREF remains slightly longer assessment of quality of life is appropriate, for than some other short forms of quality of life example, in routine clinical work, large scale . et al assessments (e.g. the SF-12 ; see Ware epidemiological studies and in clinical trials. 1996), but encompasses a larger number of domains that are integral to the assessment of REFERENCES quality of life ; notably the social relationships and environment domains that are not always Bentler, P. M. & Wu, E. J. C. (1995). EQS for Windows Users Guide . Encino, Multivariate Software, Inc. : CA. included in other assessments. In research studies Berwick, D. M., Murphy, J. M., Goldman, P. A., Ware, J. E., where only certain domains of quality of life are Barsky, A. J. & Weinstein, M. C. (1991). Performance on a Æve- of interest, there is the option to include only item mental health screening test. Medical Care 29 , 169±176. Orley, J. & Kuyken, W. (eds.) (1994) Quality of Life Assessment : those domains relevant to the study. However, International Perspectives. Springer Verlag : Heidelberg. as we have argued elsewhere, if quality of life is Szabo, S. on behalf of the WHOQOL Group (1996). The World conceptualized as a multi-dimensional construct, Health Organization Quality of Life (WHOQOL) Assessment

8 The WHOQOL Group 558 Quality of Life and Pharmaeconomics in Clinical Instrument. In ). Development of the WHOQOL : b WHOQOL Group (1994 , 2nd edn (ed. B. Spilker), pp. 355±362. Lippincott-Raven Trials rationale and current status. International Journal of Mental Publishers : Philadelphia, New York. , 24±56. 23 Health Ware, J. E., Kosinski, M. & Keller, S. D. (1996). A 12-item short- WHOQOL Group (1995). The World Health Organization Quality , 220±228. form health survey. 34 Medical Care of Life assessment (WHOQOL) : position paper from the World WHOQOL Group (1994 ). The development of the World Health a Health Organization. , 1403±1409. Social Science and Medicine 41 Organization quality of life assessment instrument (the WHOQOL Group (1998). The World Health Organization Quality Quality of Life Assessment : International Per- WHOQOL). In of Life Assessment (WHOQOL) : development and general spectives (ed. J. Orley and W. Kuyken), pp. 41±57. Springer psychometric properties. Social Science and Medicine (in the Verlag : Heidelberg. press).

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