The World Health Organization quality of life assessment (WHOQOL): Development and general psychometric properties1
Introduction
The general concept of quality of life was initially considered a useful adjunct to traditional concepts of health and functional status. An ideal health assessment, therefore, would include a measure of the person's physical health, a measure of physical, social and psychological functioning, and a measure of quality of life. Such an assessment would cover key physical, psychological, social and spiritual domains of life. Early attempts at assessments that went beyond physical health status merely examined functional status, sometimes as a rating on a single scale, rather than the broader concept of quality of life. Although such single dimensional scales have poor reliability (e.g. Clark and Fallowfield, 1986), they continue to be used in related forms such as the Axis V Global Assessment of Functioning scale in DSM-IV (American Psychiatric Association, 1994). Such scales, unfortunately, attempt to condense a complex multidimensional concept into a single Procrustean dimension. To devise a measure of quality of life that is both reliable and valid, a broad range of potentially independent domains covering all important aspects of quality of life is necessary. Furthermore, to devise a measure that is reliable and valid cross-culturally requires a different approach to instrument development (see Kuyken et al., 1994; Patrick et al., 1994; Bullinger et al., 1995). Therefore, an international collaboration has taken place over several years in order to develop a reliable, valid, and responsive assessment of quality of life that is applicable across cultures (The WHOQOL Group, 1994a, The WHOQOL Group, 1994b, The WHOQOL Group, 1995).
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The WHOQOL: Development of the pilot form
The rationale for the development of the WHOQOL, its conceptual background, the proposed uses and the steps taken to develop the pilot version of the WHOQOL have been described in detail in several recent publications (i.e. The WHOQOL Group, 1994a, The WHOQOL Group, 1994b, The WHOQOL Group, 1995; Orley and Kuyken, 1994). In brief, the aim was to develop a quality of life assessment that would be applicable cross-culturally. Rather than simply developing an assessment in one language and
Research aims
The piloting and subsequent psychometric evaluation are described in the present paper. It had several aims:
(1) to examine the construct validity of the WHOQOL domain and facet structure, and refine and reduce it accordingly
(2) to select the best questions for each facet with the aim of producing a version of the WHOQOL for use in the field trials
(3) to establish the WHOQOLs psychometric properties.
Design
A cross-sectional design was used. An agreed-upon standardised study protocol was followed in the 15 centres who participated in this phase of the study (World Health Organization, 1993).
The field centres
To ensure that the collaboration was genuinely international, field centres were selected to provide differences in level of industrialisation, available health services, and other markers relevant to the measurement of quality of life (e.g. role of the family, perception of time, perception of self, dominant
General descriptions of the sample
The data presented in Table 2 provide summary descriptions of the samples from the 15 centres in terms of age, gender, health status, and sample size. As would be expected, the statistics show that there were some differences between the centres for these descriptive statistics. Where appropriate therefore, later tables will include both raw facet and domain scores, and, in addition, scores that have been adjusted for age, sex, and health status.
Missing values
There were very few missing values in the data
General discussion
The analyses presented in this paper are remarkable in that they demonstrate that it has been possible to develop a measure of quality of life that is reliable and valid for use in a diverse range of cultures. The initial development of the pilot WHOQOL included input at a conceptual level from culturally diverse centres; thus, no centre provided the base instrument which was then merely translated into other languages. Instead, a general instrument was developed through an iterative process
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This paper was drafted by Mick Power and Willem Kuyken on behalf of the WHOQOL Group. The WHOQOL group comprises a coordinating group, collaborating investigators in each of the field centres and a panel of consultants. Dr. J. Orley directs the project. The work reported on here was carried out in the 15 initial field centres in which the collaborating investigators were: Professor H. Herrman, Dr. H. Schofield and Ms. B. Murphy, University of Melbourne, Australia; Professor Z. Metelko, Professor S. Szabo and Mrs. M. Pibernik-Okanovic, Institute of Diabetes, Endocrinology and Metabolic Diseases and Department of Psychology, Faculty of Philosophy, University of Zagreb, Croatia; Dr. N. Quemada and Dr. A. Caria, INSERM, Paris, France; Dr. S. Rajkumar and Mrs. Shuba Kumar, Madras Medical College, India; Dr. S. Saxena and Dr. K. Chandiramani, All India Institute of Medical Sciences, New Delhi, India; Dr. M. Amir and Dr. D. Bar-On, Ben-Gurion University of the Negev, Beer-Sheeva, Israel; Dr. Miyako Tazaki, Department of Science, Science University of Tokyo, Japan and Dr. Ariko Noji, Department of Community Health Nursing, St. Luke's College of Nursing, Japan; Professor G. van Heck and Dr. J. De Vries, Tilburg University, The Netherlands; Professor J. Arroyo Sucre and Professor L. Picard-Ami, University of Panama, Panama; Professor M. Kabanov, Dr. A. Lomachenkov and Dr. G. Burkovsky, Bekhterev Psychoneurological Research Institute, St. Petersburg, Russia; Dr. R. Lucas Carrasco, University of Barcelona, Spain; Dr. Yooth Bodharamik and Mr. Kitikorn Meesapya, Institute of Mental Health, Bangkok, Thailand; Dr. S. Skevington, University of Bath, U.K.; Professor D. Patrick, Ms. M. Martin and Ms. D. Wild, University of Washington, Seattle, U.S.A. and Professor W. Acuda and Dr. J. Mutambirwa, University of Zimbabwe, Harare, Zimbabwe. In addition to the expertise provided from the centres, the project has benefited from considerable assistance from: Dr. M. Bullinger, Dr. A. Harper, Dr. W. Kuyken, Professor M. Power and Professor N. Sartorius.