International Literature Review on WHODAS II - LIFE SPAN pdf.6.pdf · The WHODAS II has been used in 54 studies,of which 51 articles are pub-lished in international journals, 2 conference
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Abstract
This review is a critical analysis regarding the study and utilization of theWorld Health Organization Disability Assessment Schedule II (WHO-DAS II) as a basis for establishing specific criteria for evaluating relevantinternational scientific literature. The WHODAS II is an instrument devel-oped by the World Health Organisation in order to assess behaviourallimitations and restrictions related to an individual’s participation, inde-pendent from a medical diagnosis. This instrument was developed by theWHO’s Assessment, Classification and Epidemiology Group within theframework of the WHO/NIH Joint Project on Assessment and Classifica-tion of Disablements.To ascertain the international dissemination level of for WHODAS II’sutilization and, at the same time, analyse the studies regarding the psycho-metric validation of the WHODAS II translation and adaptation in otherlanguages and geographical contests. Particularly, our goal is to highlightwhich psychometric features have been investigated, focusing on the fac-torial structure, the reliability, and the validity of this instrument.International literature was researched through the main data bases of in-dexed scientific production: the Cambridge Scientific Abstracts – CSA,PubMed, and Google Scholar, from 1990 through to December 2008. Thefollowing search terms were used: “whodas”, in the field query, plus “title”and “abstract”.
* Received: 19 March 2009, Revised: 8 May 2009, Accepted: 8 May 2009.
1 Department of Human and Educational Sciences, University of Perugia, InterdisciplinaryResearch Centre on Disability and Technologies for Autonomy (CIRID) “Sapienza” Univer-sity of Rome, e-mail: [email protected]
2 Ph.D. in Cognitive, Psycho-physiological, and Personality Psychology, InteruniversityCenter for Research on Cognitive Processing in Natural and Artificial System (ECONA) -“Sapienza” University of Rome.
3 Interdisciplinary Research Centre on Disability and Technologies for Autonomy(CIRID) “Sapienza” University of Rome.
83
Life Span and Disability / XII, 1 (2009), 83-110
International Literature Review on WHODAS II (World Health Organization Disability Assessment Schedule II)
Stefano Federici,1 Fabio Meloni,2 & Alessandra Lo Presti1
The WHODAS II has been used in 54 studies, of which 51 articles are pub-lished in international journals, 2 conference abstracts, and one disserta-tion abstract. Nevertheless, only 7 articles are published in journals andconference proceedings regarding disability and rehabilitation. Othershave been published in medical and psychiatric journals, with the aim ofindentifying comorbidity correlations in clinical diagnosis concerning pa-tients with mental illness. Just 8 out of 51 articles have studied the psycho-metric properties of the WHODAS II. The instruments have been trans-lated into 11 languages and administered to a total of 88,844 subjects. Fi-nally, the WHODAS II is prevalently used in the medical field, with majoremphasis in the specialities of psychiatry, general medicine, and rehabili-tation.All studies point out that WHODAS II as an effective and reliable instru-ment in order to assess the disability, individual functioning and partici-pation levels. Furthermore, they often suggest administering the WHO-DAS II along with quality of life measures. Finally, the studies about thepsychometric properties of the instrument agree in considering the WHO-DAS II a reliable and valid tool for disability assessment.
Keywords: WHODAS II, WHO classifications, Biopsychosocial model,Disability classifications
1. Introduction
1.1. The classifications of disability: ICIDH and ICF1.1.1. The ICIDHSince 1948 the World Health Organization (WHO) has been the spe-
cialized agency of the United Nations to review the international nomen-clature of diseases and standardize the methods of diagnosis (WHO, 1948).The success obtained from the edition of International Classification of Dis-ease (ICD) led, in the early 1970s, to the preparation of a classification ofthe consequences of disease. Since 1975 there has been in circulation, as aninternal document of the WHO, a version of the International Classificationof Impairments, Disabilities, and Handicaps (ICIDH). Subsequently, theWHO requested Philip Wood to collect the material produced until thenand transform it into a classification. In 1980 the WHO published the re-sults, the ICIDH, in a book for study and research (World Health Organi-zation (WHO), 1980; cfr. also: Pfeiffer, 1998; Üstün, Bickenbach, Badley, &Chatterji, 1998). The aim of the ICIDH was to clarify some concepts andterminology that were used with reference to disability, to facilitate re-search and policy choices in an area of growing importance. The classifica-tion has been translated into many languages and used to conduct statisti-cal surveys on population, to encode information on the health of people
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Life Span and Disability Federici S. / Meloni F. / Lo Presti A.
and as a starting point for the implementation of social and welfare policies.The ICIDH has an unquestionable merit: it introduced, from the healthpoint of view, a first-time distinction and definition of terms that, until then,had been used interchangeably, creating considerable confusion amonghealth professionals.
The ICIDH proposes a tripartite distinction between Impairment, Dis-ability and Handicap, defined as follows:
- Impairment: any loss, or abnormality, of psychological, physiological oranatomical structures or functions.
- Disability: any limitation or loss (due to an impairment) of ability toperform an activity or variations in the way considered normal for a humanbeing.
- Handicap: disadvantage experienced by a particular person, the resultof an impairment or a disability that limits or prevents the opportunity tofill the role usually just one person (in relation to age, sex and socio-cultur-al factors).
In the definition of handicap a clear causal relationship is established be-tween handicap and other conditions, i.e. the handicap is always the resultof an impairment or the consequence of a disability. Therefore, the impair-ment, or disability, or both, are necessary so that we can talk about handi-cap; and yet, they are not sufficient, since not all impairments producehandicap. It is essential, according to the ICIDH, that the handicap is livedor experienced as such, that the person is aware of the disproportion be-tween expected performance and that actually given because of the condi-tion of disability.
The ICIDH was designed with the intent to offer a non-medical modelof disability, and this is demonstrated by the substantial lack of aetiologicalfactors. And yet, as the ICIDH declares that among the three levels of im-pairment, disability and handicap there is a relationship that can not be sim-ply linear, literature evaluates the classification as the product of a culturalcontext in which the handicap was considered the product of an impair-ment and/or a disability. While it is acknowledged that the ICIDH is un-doubtedly a tool developed with the goal of utilizing a common and uni-versal language on disability at an international level (Üstün, Bickenbach,et al., 1998; Bickenbach, Chatterji, Badley, & Üstün, 1999; Buono & Zagaria,1999; Üstün, Chatterji, et al., 2001), it has been the focus of great controver-sy, especially animated by the supporters of the social model of disabilitywho considered the Classification too oriented towards the medical model(Chamie, 1995; Pfeiffer, 1998), despite what is claimed by its editors (Bury,2000). In any case, we can only note that each of the three key concepts ofclassification is defined in relation to a concept of normality that it is as-sumed to be related primarily to biomedical categories.
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International Literature Rewiew on WHODAS II
1.1.2. The ICFIn 2001, the World Health Organization adopted the new International
Classification of Functioning, Disability and Health.The final document col-lects work published over the last decade and which has had as its goal revi-sion of the ICIDH. The nine years dedicated to completing the reviewprocess will certainly give an idea of the complexity of the problems dealtwith and the extent of the criticisms raised by the proposal for a new Classi-fication (Üstün, Bickenbach, et al., 1998; Pfeiffer, 1998; Hurst, 2000; Pfeiffer,2000).As has already been pointed-out, the criticisms about several concep-tual aspects of the ICIDH, which has determined the need for a revision, are:
- The reference to a medical model of disability, which is sequential andcausal, according to which disability (or/and handicap) is regarded as thedirect outcome of an impairment of the individual.
- The application of an approach based on a linear succession consider-ing the handicap as a direct consequence of impairment.
- The presence of a negative terminological bias, as most conditions aredescribed by using a negative terminology.
From an operative viewpoint, the main limitations characterising theICIDH were given by the use of terms which were inadequate with refer-ence to the contemporary scientific context, as well as by the impossibilityto compare data from different contexts (Chatterji et al., 2001; Rehm et al.,2001; Trotter et al., 2001; Üstün, Chatterji et al., 2001).
The linear progressive perspective applied in the old classification isabandoned in the ICF, to implement a circular interactive model in whichfunctioning and disability of a person are considered as the product of thedynamic interaction between health conditions and contextual factors, in-cluding personal and environmental ones.
The structure of this new classification can thus be divided into two“parts”, each one including two “components”: Part 1, “Functioning andDisability”; including the following components: a) body functions andstructures and b) activities and participation; Part 2, “Contextual factors”,including the following components: a) environmental factors and b) per-sonal factors. Each component is formed by several domains, and each do-main is organised in categories at different levels, which represents theunits of classification.
Moreover, in contrast with the ICIDH, the ICF sets a common, “stan-dard” language, which not only allows a common understanding and use byoperators belonging to different professional areas, but is also easily applic-able to remarkably different environmental contexts.
There are two consequences stemming from this approach:- First, the context and the life environment of each individual dramati-
cally influences the level of her/his functioning in presence of a given dis-ability and, given the same impairment, different contexts have very diverseeffects on individual functioning and adaptation.
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Life Span and Disability Federici S. / Meloni F. / Lo Presti A.
- Secondly, any person during her/his life can experience a changing stateof health which, in a given environment, becomes disabling, i.e. influencingnegatively on the person’s functioning abilities.
The ICF, wanting to describe functional states of each individual andhis/her limitations, proposes a dynamic model of mutual interaction be-tween health conditions and contextual factors.
The presence of an impairment necessarily implies a “cause”, which maynot be sufficient to explain the result of impairment.
Therefore, the disability is the complex and multiderminated outcome ofthree main factors: the health of an individual, the personal and environ-mental factors.The triadic reciprocal causation of factors exceeds the linearetiological prospect which from altered states of health leads to disability.In the new biopsychosocial model, the disability, understood both as a lim-itation of individual abilities as well as restrictions in social participation, iscertainly related to a state of health, conventionally regarded as pathologi-cal, but not necessarily caused by the same condition as in the linear modelof the ICIDH.
The biopsychosocial model provides a perspective on the health conceptthat is not always in line with the medical one. Since different environmentsmay have a very different impact on the same individual with a certainhealth condition, like the ICF notes «two persons with the same diseasemay have different levels of functioning and two persons with the same lev-el of functioning not necessarily have the same condition of health» (ICF, p.12). The interconnections between biological, structural, functional factors,of abilities, social participation, various contexts and personal and psycho-logical dimensions do not allow simple aetiologies, focusing only on thephysiopathological, anatomical and neurological levels.
1.2. Traditional tools for measuring and assessing the disabilit.Specific rating scales for measuring disability can be regarded as the
Barthel Index and FIM (Functional Independence Measure). The first onehas the advantage that it can be administered quickly and without specialtraining; the second one involves slightly longer times of administration andrequires specific training.
The Barthel Index (Mahoney & Barthel, 1965) is an ordinal scale withtotal score from 0 (totally dependent) to 100 (totally independent) andcomprising 10 items. The index shows the level of autonomy in various ac-tivities: feeding, taking a bath, personal hygiene, dressing, rectum and blad-der control, transfers to bathroom or chair/bed, walking and climbing stairs.The performance should be established using the best available data, theusual sources are direct questions to the patient, friends/relatives and nurs-es, but also direct observation and common sense are important. Excellentvalidity and reliability are the strong points of the index that, however, ap-pears to be subject to a “plateau” effect in highlighting the changes in more
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International Literature Rewiew on WHODAS II
complex functions. Reflecting a background determined by the culturalprevalence of the medical model, the Barthel index assigns an absolutelyrelevant weight to functions such as continence or mobility and not theleast, also explores self-sufficiency in cognitive areas. Moreover, it is not areal standard, since there are at least 8 different versions published that dif-fer in the number of items and methodology in assignment of scores.
Also the FIM (Keith, Granger, Hamilton, & Sherwin, 1987) measuresself-sufficiency in 18 activities of daily living (like dressing, feeding, loco-motion, etc.) that cumulatively provide a quantitative index of disability.Beyond the advantages of scale, such as the statistical validity, the simplici-ty of implementation and the ability to compare data at the internationallevel, thanks to its wide distribution, the FIM is an instrument that assessesthe level of self-sufficiency of a person from the perspective of an outsideobserver, leaving no space for self-evaluation.
1.3. The assessment of disability according to the biopsychosocial modelThe direct application of the ICF and its codes appeared since the be-
ginning as a rather demanding and complex task: for this reason, the WHOintroduced the ICF Checklist (WHO, 2003), which allows the description ofthe functioning profile of a subject based on 128 codes selected among thethousands forming the whole ICF (in the second level there are already 362codes, that become 1.424 in the third and fourth level) (ivi, p. 3). The ICFchecklist is not really an instrument for measure or assessment: its utilitycomes from the possibility to “open” the codes on the basis of the identifi-cation of a person’s functioning problem, and at the same time to establishwhether, and in which measure, the environment acts either as barrier orconversely facilitates the individual.
The ICF Checklist is administered to the patient or his/her caregiver. Itis structurally divided into four parts: the introductory part, which includesbiographical data, the ICD-10 code, and the specification of informationsource; the first part, containing the list of codes of Body Functions (b) andBody Structures (s); the second part, comprising the list of codes for Activ-ities and Participation (d); and finally, the third part, containing the list ofcodes relating to Environmental Factors (e). In Italy, the translation, vali-dation, and a first application in the research and clinical field were coordi-nated by the Disability Italian Network (DIN) in 2004.
The WHODAS II, however, proposes to evaluate the disability from adifferent viewpoint from that of the normal tools of measurement. In fact,while the ICF Checklist was developed as a practical tool to elicit clinicians’overall impressions of a patient’s condition and to record information onfunctioning and disability, the WHODAS II rates the nature of disability di-rectly from the patient’s responses. Therefore, the ICF Checklist offers anexternal (objective) view on disability while the WHODAS II does an in-ternal (subjective) one.
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Life Span and Disability Federici S. / Meloni F. / Lo Presti A.
The WHODAS II assesses the limitations in activities and restrictions inparticipation experienced by an individual, independently from a medicaldiagnosis. Specifically, the instrument is designed to evaluate the function-ing of the individual in six activity domains:
1. Understanding and communicating 2. Getting around 3. Self-care 4. Getting along with people 5. Life activities 6. Participation in society There are different forms of the WHODAS II, each of them has been
structured in relation to the number of item (6, 12, 24, 12 + 24 and 36), themode of administration (self-administered or administered by an inter-viewer) and the user to whom the interview is proposed (subject, clinician,caregiver). In any case, the WHO recommends the use of the 36 item formadministered by an interviewer for completeness.
The participants interviewed are asked to indicate the experienced levelof “difficulty” (none, mild, moderate, severe, extreme), by taking into accountthe way in which they normally perform a given activity, and including theuse of whatever support or/and help by a person (aids). For every item re-ceiving a positive answer, the subsequent question asks the number of days(“in the last 30 days”) in which the interviewed has met such a difficulty, interms of a 5-point ordinal scale: 1) Only one day; 2) Up to a week = from 2to 7 days; 3) Up to two weeks = from 8 to 14 days; 4) More than two weeks= from 15 to 29 days; 5) Every day = 30 days.
Then, the person is asked how much the difficulties have interfered withhis/her life.
Respondents should answer the questions according to the followingreferences:
1. Degree of difficulty (the increase in the effort, discomfort or pain, orslowness, or differences in general);
2. Health conditions (disease or illness, or injury, or mental or emotionalproblems, or related to alcohol, or problems associated with drug abuse);
3. The last 30 days;4. The average between “good” and “bad” days;5. The way in which they normally perform the activity.The items that refer to activities not experienced in the last 30 days are
not classified.
2. Purpose and methodology
The general aim of the study presented here is to check the spread of theWHODAS II at international level and in different fields of application
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International Literature Rewiew on WHODAS II
Specifically, given the widespread consent universally reached about theusefulness of the WHODAS II, we need to verify its reliability in assessingthe functioning and the self-perception of disability in persons with normalabilities and disabled participants, both through the analysis of some psy-chometric characteristics such as reliability, validity and factorial structure,either through correlational analysis. The bibliographic review, in the nextparagraph, is intended to provide an overview, as complete as possible, ofscientific studies that have been made using the WHODAS II, since its pub-lication until now. In most of these studies, moreover, the WHODAS II wasused in combination with other assessment tools: this has allowed us to ver-ify its convergent validity, and its compatibility and complementarities withthese instruments.
A survey on the main databases of international indexed scientific pro-duction, Cambridge Scientific Abstracts – CSA and PubMed, using as keysearch the term “whodas” in the “title” and “abstract” field query, it wasfound that the WHODAS II was used in 54 works. Table 1 shows the listof the 54 studies, specifying for each the type of study, the number of par-ticipants, the nationality, the field of research and the main purposes andresults.
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Life Span and Disability Federici S. / Meloni F. / Lo Presti A.
91
International Literature Rewiew on WHODAS II
Art
icle
spu
blis
hed
in in
tern
atio
nal
jour
nals
Typ
e of
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yN
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ualit
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litat
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dyIt
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96
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e of
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der
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opin
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gY
ou
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ents
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Cor
rela
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nal
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ntit
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eem
piri
cal s
tudy
Egy
pt20
0 D
isab
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n
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ion
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f gen
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ski
lls a
mon
g yo
ung
vis
ually
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bled
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dent
s.
Cor
rela
tio
n oc
curr
ed.
4. B
aner
jee
et a
l.(2
008)
. Pre
vale
nce
of d
epre
ssio
n an
d it
s ef
fect
on
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pati
ents
wit
h ag
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acul
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Indi
a
53
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chia
try
Ass
essm
ent o
f dep
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ion
effe
cts
ondi
sabi
lity
inpa
tien
tsw
ith
visu
alm
acul
ar d
egen
erat
ion.
Cor
rela
tio
n oc
curr
ed.
5. B
aron
et a
l.(2
008)
. The
clin
imet
ric
pro
pert
ies
ofth
e w
orld
hea
lth
orga
niz
atio
n di
sabi
lity
asse
ssm
ent
sche
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le I
I in
ear
ly in
flam
mat
ory
arth
riti
s.
Psy
chom
etri
cq
uant
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rica
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dy
Can
ada
172
Med
icin
eE
valu
atio
nof
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ric
pro
pert
ies
ofth
e W
HO
DA
S II
inpa
tien
ts w
ith
earl
yin
flam
mat
ory
arth
riti
s.
Goo
d re
liabi
lity
and
vali
dity
.
6. B
onne
wyn
et a
l. (2
005)
.The
im
pact
ofm
enta
l dis
orde
rson
daily
func
tion
ing
in th
e B
elgi
an
com
mun
ity.
Epi
dem
iolo
gica
lco
rrel
atio
nal
qua
ntit
ativ
eem
piri
cal s
tudy
Bel
gium
2419
M
edic
ine
Ass
essi
ngth
e im
pact
ofm
enta
ldi
sord
ers
onda
ily fu
ncti
oni
ng o
fthe
B
elgi
an p
op
ulat
ion.
Cor
rela
tio
n oc
curr
ed.
7. B
uist
-Bou
wm
an e
t al.
(200
8).
Psy
chom
etri
c pr
ope
rtie
s of
the
Wor
ld H
ealt
h O
rgan
izat
ion
Dis
abil
ity
Ass
essm
entS
ched
ule
used
inth
eE
uro
pean
Stu
dy o
fthe
Epi
dem
iolo
gy o
f Men
tal D
isor
ders
.
Psy
chom
etri
cq
uant
itat
ive
empi
rica
l stu
dy
Net
herl
ands
8796
P
sych
iatr
yV
alid
atio
n of
the
vers
ion
ofW
HO
DA
Sus
ed in
the
Eur
ope
an S
tudy
oft
heE
pide
mio
logy
of M
enta
l Dis
orde
rs(E
SEM
eD).
Goo
d re
liabi
lity
and
vali
dity
and
fact
oria
lst
ruct
ure
conf
irm
ed.
8. C
hiso
lmet
al.
(200
5). T
he W
HO
-D
AS
II: p
sych
omet
ric
pro
pert
ies
inth
e m
easu
rem
ento
f fun
ctio
nal
heal
th s
tatu
s in
adu
lts
wit
h ac
quir
edhe
arin
g lo
ss.
Psy
chom
etri
cq
uant
itat
ive
empi
rica
l stu
dy
Uni
ted
Stat
es38
0 D
isab
ilit
yan
dre
hab
ilit
atio
n
Def
init
ion
ofth
eps
ycho
met
ric
pro
pert
ies
ofth
e W
HO
DA
S II
for
asa
mpl
e of
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lts
wit
hon
set o
f hea
ring
lo
ss.
Goo
d re
liabi
lity
and
vali
dity
.
Tab.
1 - I
nter
natio
nal l
itera
ture
on
WH
OD
AS
II
92
Life Span and Disability Federici S. / Meloni F. / Lo Presti A.
9. C
ho
pra
et a
l. (2
00
4).
Th
e
ass
ess
me
nt
of
pa
tie
nts
wit
h l
on
g-
term
psy
cho
tic
dis
ord
ers
:A
pp
lica
tio
n o
fth
eW
HO
Dis
ab
ilit
yA
sse
ssm
en
t S
che
du
le I
I.
Psy
cho
me
tric
qu
an
tita
tive
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pir
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l st
ud
y
Au
stra
lia
2
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chia
try
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lua
tio
no
f th
e W
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inp
ati
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ts t
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d f
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lon
g-t
erm
psy
cho
tic
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.
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od
re
lia
bil
ity
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dva
lid
ity.
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. Ch
op
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(20
08
).C
om
pa
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no
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isa
bil
ity a
nd
qu
ali
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f li
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sure
s in
pa
tie
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w
ith
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ng
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rm p
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oti
c d
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rde
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nd
pa
tie
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wit
h m
ult
iple
scl
ero
sis:
an
ap
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cati
on
of
the
WH
OD
isa
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ity
Ass
ess
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nt
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ed
ule
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an
d W
HO
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ali
tyo
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ife-B
RE
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rre
lati
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al
qu
an
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tive
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l st
ud
y
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stra
lia
4
0
Psy
chia
try
Co
mp
ari
son
be
twe
en
th
e a
pp
lica
tio
no
fth
e W
HO
DA
S I
I a
nd
th
e W
HO
QO
L-
BR
EF
in
the
eva
lua
tio
n o
f p
ati
en
ts w
ith
p
sych
oti
c d
iso
rde
rs a
nd
mu
ltip
lesc
lero
sis.
Co
rre
lati
on
co
nfi
rme
d.
11
. Ch
wa
stia
k e
t al.
(20
03
).D
isa
bil
ity
in
de
pre
ssio
na
nd
ba
ckp
ain
:e
va
lua
tio
no
fth
e W
orl
d H
ea
lth
Org
an
izati
on
Dis
ab
ilit
yA
sse
ssm
en
tS
che
du
le (
WH
O D
AS
II)
in
ap
rim
ary
ca
rese
ttin
g.
Psy
cho
me
tric
qu
an
tita
tive
em
pir
ica
l st
ud
y
Un
ite
dS
tate
s1
49
M
ed
icin
eE
va
lua
tio
no
f m
ea
sure
me
nt
pro
pe
rtie
so
fth
eW
HO
DA
S I
I in
tw
o d
iso
rde
rs
com
mo
nly
en
cou
nte
red
in
pri
ma
ry c
are
sett
ing
.
Go
od
va
lid
ity a
nd
resp
on
siv
en
ess
to
cha
ng
e.
12
. Do
nm
ez
et a
l. (2
00
5).
Dis
ab
ilit
ya
nd
its
eff
ect
s o
n q
ua
lity
of
life
am
on
g o
lde
rp
eo
ple
liv
ing
in
An
taly
a c
ity c
en
ter,
Tu
rke
y.
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
Tu
rke
y
84
0
Me
dic
ine
Dete
ctio
no
ffr
eq
ue
ncy
an
d s
eve
rity
leve
lo
f d
isa
bil
ity
for
old
er
pe
op
leli
vin
g i
nA
nta
lya
cit
y c
en
ter;
eva
lua
tio
no
f th
e e
ffect
s o
f d
isa
bil
ity a
nd
va
ria
ble
s a
sso
cia
ted
wit
h i
t o
n l
ivin
g c
on
dit
ion
s.
Fre
qu
en
cy a
nd
se
ve
rity
de
tect
ed
; co
rre
lati
on
de
tect
ed
.
13
. Ert
ug
rul
et a
l. (2
004
). P
erc
ep
tio
no
f st
igm
a a
mo
ng
pa
tie
nts
wit
h
sch
izo
ph
ren
ia.
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
Tu
rke
y
60
P
sych
iatr
yM
ea
sure
me
nt
of
the
re
lati
on
ship
be
twe
en
th
e s
ym
pto
ms
an
d o
the
rch
ara
cte
rist
ics
of
sch
izo
ph
ren
ic p
ati
en
tsw
ith
se
lf-p
erc
eiv
ed
sti
gm
a.
Co
rre
lati
on
occ
urr
ed
.
14
. ES
EM
eD
/MH
ED
EA
200
0in
ve
stig
ato
rs. (
20
04
). D
isa
bil
ity
an
dq
ua
lity
of
life
im
pa
ct o
fm
en
tal
dis
ord
ers
in
Eu
rop
e.
Ep
ide
mio
log
ica
lco
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
Be
lgiu
m,
Ge
rma
ny,
Ita
ly, S
pa
in,
Fra
nce
an
dN
eth
erl
an
ds
21
42
5
Psy
chia
try
Su
rve
y o
n t
he
im
pa
ct o
fth
e s
tate
of
me
nta
l h
ea
lth
an
d s
pe
cifi
cm
en
tal
an
dp
hy
sica
l d
iso
rde
rso
n w
ork
pe
rfo
rma
nce
an
d q
ua
lity
of
life
in
six
Eu
rop
ea
n c
ou
ntr
ies.
Co
rre
lati
on
s o
ccu
rre
d.
15
. Fe
de
rici
et a
l. (2
00
8).
Wo
rld
He
alt
h O
rga
niz
ati
on
Dis
ab
ilit
y
Ass
ess
me
nt
Sch
ed
ule
II
(WH
OD
AS
II):
A c
on
trib
uti
on
to
th
eIt
ali
an
va
lid
ati
on
.
Psy
cho
me
tric
qu
an
tita
tive
em
pir
ica
l st
ud
y
Ita
ly
50
0
Dis
ab
ilit
ya
nd
reh
ab
ilit
ati
on
Va
lid
ati
on
of
the
Ita
lia
n v
ers
ion
of
the
W
HO
DA
S I
I.G
oo
d v
ali
dit
y a
nd
reli
ab
ilit
y a
nd
fact
ori
al
stru
ctu
re c
on
firm
ed
.
16
. Ga
lla
gh
er
et a
l. (2
004
). L
eve
ls o
fa
bil
ity
an
d f
un
ctio
nin
g: u
sin
g t
he
W
HO
DA
SII
ina
nIr
ish
con
tex
t
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
lst
ud
y
Ire
lan
d
13
04
D
isa
bil
ity
an
dre
ha
bil
ita
tio
Co
rre
lati
on
al
an
aly
sis
be
twe
en
so
cio
-d
em
og
rap
hic
va
ria
ble
s,ca
use
s o
fd
isa
bil
ity
an
dd
om
ain
so
fin
div
idu
al
Co
rre
lati
on
s co
nfi
rme
d.
93
International Literature Rewiew on WHODAS II
the
WH
OD
AS
II.
17
. Go
ya
let
al.
(20
02
).E
ffic
acy
of
Me
no
san
, a p
oly
he
rba
l fo
rmu
lati
on
in t
he
ma
na
ge
me
nt
of
me
no
pa
usa
lsy
nd
rom
e w
ith
re
spe
ctto
qu
ali
ty o
fli
fe.
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
Ind
ia4
0M
ed
icin
eA
sse
ssm
en
t o
fth
e e
ffect
s o
fM
en
osa
n, a
po
lyh
erb
alfo
rmu
lati
on
, on
qu
ali
tyo
fli
fe i
n m
en
op
au
sal
wo
me
n.
Co
rre
lati
on
co
nfi
rme
d;
eff
icacy
of
Me
no
san
de
mo
nst
rate
d.
18
. Hu
dso
net
al.
(20
08
). C
lin
ica
lco
rre
late
s o
f q
ua
lity
of
life
in
syst
em
ic s
cle
rosi
s m
ea
sure
d w
ith
the
W
orl
d H
ea
lth
Org
an
iza
tio
nD
isa
bil
ity
Ass
ess
me
nt
Sch
ed
ule
II.
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
Ca
na
da
33
7M
ed
icin
eId
en
tifi
cati
on
of
clin
ica
l fe
atu
res
of
syst
em
ic s
cle
rosi
s th
at
be
stco
rre
late
wit
h t
he
qu
ali
ty o
f li
fe r
ela
ted
to
th
e
he
alt
h o
f p
ati
en
ts.
Cli
nic
al co
rre
late
sid
en
tifi
ed
.
19
. Hu
dso
net
al.
(20
08
). Q
ua
lity
of
life
in
sy
stem
icsc
lero
sis:
psy
cho
me
tric
pro
pe
rtie
s o
fth
eW
orl
d H
ea
lth
Org
an
iza
tio
nD
isa
bil
ity
Ass
ess
me
nt
Sch
ed
ule
II.
Psy
cho
me
tric
qu
an
tita
tive
em
pir
ica
l st
ud
y
Ca
na
da
40
2M
ed
icin
eS
tud
yo
f va
lid
ity o
fth
eW
HO
DA
S I
I in
pa
tie
nts
wit
h s
yst
em
ic s
cle
rosi
s.G
oo
d v
ali
dit
y.
20
. Ja
nca
et a
l.(1
99
6).
Th
eW
orl
dH
ea
lth
Org
an
izati
on
Sh
ort
D
isa
bil
ity
Ass
ess
me
nt
Sch
ed
ule
(WH
O D
AS
-S):
ato
ol
for
the
ass
ess
me
nt
of
dif
ficu
ltie
s in
se
lect
ed
are
as
of
fun
ctio
nin
g o
f p
ati
en
tsw
ith
m
en
tal
dis
ord
ers
.
An
aly
tica
l st
ud
yS
wit
zerl
an
d0
P
sych
iatr
ya
nd
me
dic
ine
Stu
dy
of
cha
ract
eri
stic
s o
f th
eW
HO
DA
S-S
as
a c
lin
ica
l to
ol
for
eva
lua
tio
no
f in
div
idu
alfu
nct
ion
ing
in
psy
chia
tric
su
bje
cts.
Dete
ctio
n o
fa
go
od
uti
lity
an
d e
ase
of
use
a
nd
acc
ep
tab
lere
lia
bil
ity
for
use
by
clin
icia
ns
be
lon
gin
g t
od
iffe
ren
t sc
ho
ols
an
dp
sych
iatr
ic t
rad
itio
ns.
21
. Ke
mm
ler
et a
l. (2
00
3).
Qu
ali
ty o
fli
fe o
fH
IV-i
nfe
cte
d p
ati
en
ts:
Psy
cho
me
tric
pro
pe
rtie
s a
nd
va
lid
ati
on
of
the G
erm
an
ve
rsio
no
fth
e M
QO
L-H
IV.
Psy
cho
me
tric
qu
an
tita
tive
em
pir
ica
l st
ud
y
Ge
rma
ny
2
07
M
ed
icin
eC
on
ve
rge
nt
va
lid
ity
stu
dy
of
the
G
erm
an
ve
rsio
n o
fth
eM
ult
idim
en
sio
na
l Q
ua
lity
of
Lif
eQ
ue
stio
nn
air
efo
r H
IV/A
IDS
on
asa
mp
le o
f H
IV-i
nfe
cte
d p
ati
en
ts.
Go
od
va
lid
ity a
nd
reli
ab
ilit
y o
fth
e
Mu
ltid
ime
nsi
on
al
Qu
ali
ty o
f L
ife
Qu
est
ion
na
ire
fo
rH
IV/A
IDS
; co
nv
erg
en
tva
lid
ity
de
mo
nst
rate
d.
22
. Ke
ssle
ret
al.
(20
03
).T
he
E
pid
em
iolo
gy
of
Ma
jor
De
pre
ssiv
e
Dis
ord
er:
Re
sult
s fr
om
th
e;N
ati
on
al
Co
mo
rbid
ity
Su
rve
y R
ep
lica
tio
n(N
CS
-R).
Ep
ide
mio
log
ica
lco
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
Un
ite
dS
tate
s9
09
0
Me
dic
ine
Su
rve
y o
np
reva
len
ce,c
orr
ela
tio
n a
nd
clin
ica
l re
leva
nce
of
the D
SM
dis
ord
ers
an
d a
sse
ssm
en
t o
ftr
eatm
en
ts a
de
qu
acy
.
Pre
va
len
ce, c
orr
ela
tes
an
d c
lin
ica
l re
leva
nce
ide
nti
fie
d; i
na
de
qu
acy
of
tre
atm
en
td
ete
cte
d.
23
. Kim
et a
l. (2
00
5).
Ph
ysi
cal
he
alt
h,
de
pre
ssio
n a
nd
co
gn
itiv
efu
nct
ion
as
corr
ela
tes
of
dis
ab
ilit
y i
n a
n o
lde
rK
ore
an
po
pu
lati
on
.
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
So
uth
Ko
rea
12
04
P
sych
iatr
yS
urv
ey
on
ind
ep
en
de
nt
ass
oci
ati
on
sb
etw
ee
n p
hy
sica
lh
ea
lth
, de
pre
ssio
n,
cog
nit
ive
fu
nct
ion
an
d d
isa
bil
ity
in
the
o
lde
r K
ore
an
po
pu
lati
on
.
Co
rre
lati
on
s co
nfi
rme
d.
24
. Kim
et a
l. (2
00
8).
BD
NF
tt
till
dif
ith
Co
rre
lati
on
al
qu
an
tita
tive
So
uth
Ko
rea
50
0
Psy
chia
try
Su
rve
y o
n t
he
ro
leo
fa g
en
oty
pe
(va
l66
met)
of
the
ne
uro
tro
ph
icfa
cto
rC
orr
ela
tio
n c
on
firm
ed
.
94
Life Span and Disability Federici S. / Meloni F. / Lo Presti A.
ass
oci
ati
on
be
twe
en
in
cid
en
t st
rok
ea
nd
de
pre
ssio
n.
em
pir
ica
l st
ud
yd
eri
ve
dfr
om
the b
rain
(B
DN
F)
in t
he
ass
oci
ati
on
be
twe
en
str
ok
e a
nd
d
ep
ress
ion
.2
5. L
ast
raet
al.
(20
00
).T
he
cl
ass
ific
ati
on
of
firs
t e
pis
od
e
sch
izo
ph
ren
ia: a
clu
ste
r-a
na
lyti
cal
ap
pro
ach
.
Qu
ali
tati
ve
em
pir
ica
l st
ud
yS
pa
in8
6
Psy
chia
try
Ch
eck
th
e c
lass
ific
ati
on
of
asc
hiz
op
hre
nic
po
pu
lati
on
into
sub
gro
up
s fo
r si
mil
ar
sym
pto
ms
pro
file
s.
Div
isio
n i
nto
sub
gro
up
s co
nfi
rme
d,
bu
t n
ot
pre
dic
tiv
e.
26
. MaG
PIe
Re
sea
rch
Gro
up
.(2
00
4).
Ge
ne
ral
pra
ctit
ion
er
reco
gn
itio
no
fm
en
tal
illn
ess
in
the
a
bse
nce
of
a ‘
go
ld s
tan
da
rd’.
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
New
Ze
ala
nd
84
5
Psy
chia
try
Co
mp
ari
son
be
twe
en
th
e g
en
era
lp
ract
ice o
f re
cog
nit
ion
of
me
nta
l il
lne
ssa
nd
th
eca
ses
ide
nti
fie
db
y d
iag
no
stic
inst
rum
en
ts a
nd
scr
ee
nin
g.
Co
rre
lati
on
is
no
tve
rifi
ed
; va
ria
bil
ity
be
twe
en
in
stru
me
nts
a
nd
be
twe
en
clin
ica
lo
pin
ion
an
d s
cre
en
ing
an
d d
iag
no
stic
test
s.2
7. M
aG
PIe
Re
sea
rch
Gro
up
.(2
00
3).
Th
e n
atu
rea
nd
pre
va
len
ceo
f p
sych
olo
gic
al
pro
ble
ms
inN
ew
Ze
ala
nd
pri
ma
ry h
ea
lth
care
:are
po
rt o
n M
en
talH
ea
lth
an
dG
en
era
l P
ract
ice I
nve
stig
ati
on
(MaG
PIe
).
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
New
Ze
ala
nd
70
M
ed
icin
eS
tud
yo
fth
e d
eg
ree
of
dis
ab
ilit
y a
nd
oth
er
fact
ors
th
at
infl
ue
nce
th
ere
cog
nit
ion
, ma
na
ge
me
nt,
cou
rse
an
do
utc
om
e o
fm
en
tal
dis
ord
ers
in
pa
tie
nts
o
f N
ew
Ze
ala
nd
.
Co
rre
lati
on
s co
nfi
rme
d.
28
. Matí
as-
Ca
rre
loet
al.
(20
03
). T
he
S
pa
nis
h t
ran
sla
tio
n a
nd
cu
ltu
ral
ad
ap
tati
on
of
five
me
nta
lh
ea
lth
ou
tco
me
me
asu
res.
Qu
ali
tati
ve
em
pir
ica
l st
ud
y
of
tra
nsl
ati
on
an
d a
da
pta
tio
n
Sp
ain
13
0M
ed
icin
eS
pa
nis
h t
ran
sla
tio
n a
nd
ad
ap
tati
on
of
five
me
asu
res
of
me
nta
lh
ea
lth
.S
em
an
tic,
tech
nic
al
an
dco
nte
nt
eq
uiv
ale
nce
d
em
on
stra
ted
.
29
. McA
rdle
et a
l.(2
00
5).
Th
e W
HO
-D
AS
II:
me
asu
rin
g o
utc
om
es
of
he
ari
ng
aid
in
terv
en
tio
n f
or
ad
ult
s.
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
Un
ite
dS
tate
s3
80
D
isa
bil
ity
an
dre
ha
bil
ita
tio
n
Ass
ess
me
nt
of
react
ivit
y o
fth
eW
HO
DA
SII
to
th
esh
ort
an
d l
on
g t
erm
eff
ect
s in
ap
pli
cati
on
so
f aco
ust
icd
ev
ice
s.
Go
od
re
act
ivit
y o
fth
e
WH
OD
AS
II,
corr
ela
tio
n d
ete
cte
d.
30
. McK
ibb
inet
al.
(20
04
). A
sse
ssin
gD
isa
bil
ity i
n O
lde
r P
ati
en
ts W
ith
Sch
izo
ph
ren
ia R
esu
lts
Fro
mth
eW
HO
DA
S-I
I.
Psy
cho
me
tric
qu
an
tita
tive
em
pir
ica
l st
ud
y
Un
ite
dS
tate
s7
6M
ed
icin
eE
va
lua
tio
no
f re
lia
bil
ity
an
d v
ali
dit
yo
fth
e W
HO
DA
S I
I in
old
er
pa
tie
nts
wit
h
sch
izo
ph
ren
ia.
Str
on
g e
vid
en
ce o
fg
oo
d r
eli
ab
ilit
ya
nd
som
e e
vid
en
ce o
f g
oo
dva
lid
ity.
3
1.M
ub
ara
kA
R. (
20
05
). S
oci
al
fun
ctio
nin
g a
nd
qu
ali
ty o
f li
fe o
fp
eo
ple
wit
h s
chiz
op
hre
nia
in
th
en
ort
he
rn r
eg
ion
of
Ma
lay
sia
.
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
Ma
lay
sia
25
8
Me
dic
ine
Inve
stig
ati
on
on
th
e r
ela
tio
nsh
ipb
etw
ee
n s
oci
alfu
nct
ion
ing
an
d q
ua
lity
of
life
of
pe
op
le w
ith
sch
izo
ph
ren
ia i
nM
ala
ysi
a.
Co
rre
lati
on
co
nfi
rme
d.
32
. No
rto
net
al.
(20
04
). P
sych
iatr
icm
orb
idit
y,d
isa
bil
ity
an
d s
erv
ice
use
am
on
gst
pri
ma
ry c
are
att
en
de
rs i
nF
ran
ce.
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
Fra
nce
12
4
Psy
chia
try
Inve
stig
ati
on
on
th
e r
ela
tio
nsh
ipb
etw
ee
n p
sych
iatr
icm
orb
idit
y,d
isa
bil
ity
an
du
se o
f se
rvic
es
inF
ren
chp
ati
en
ts.
Co
rre
lati
on
s co
nfi
rme
d.
33
. Pe
rin
iet
al.
(20
06
).G
en
eri
ceff
ect
ive
ne
ssm
ea
sure
s:S
en
siti
vit
yto
Co
rre
lati
on
al
qu
an
tita
tive
Au
stra
lia
16
9M
ed
icin
eS
tud
yw
ith
co
nve
rge
nt
me
asu
res
on
sen
siti
vit
yto
cha
ng
ein
pe
op
lew
ith
Co
nv
erg
en
t va
lid
ity
d
em
on
stra
ted
95
International Literature Rewiew on WHODAS II
dis
ord
ers
.3
4. P
ett
ers
son
et a
l. (2
00
6).
Th
e e
ffect
of
an
ou
tdo
or
po
we
red
wh
ee
lch
air
on
act
ivit
ya
nd
pa
rtic
ipa
tio
n i
n u
sers
wit
h s
tro
ke
.
Qu
an
tita
tive
an
d
lon
git
ud
ina
le
mp
iric
al
stu
dy
Sw
ed
en
3
2D
isa
bil
ity
an
dre
ha
bil
ita
tio
n
Se
lf-e
va
lua
tio
n o
fth
e l
imit
ati
on
s in
act
ivit
ies
an
d r
est
rict
ion
sin
th
e
pa
rtic
ipa
tio
n o
f p
eo
ple
wit
h s
tro
ke
,b
efo
re a
nd
aft
er
the
use
of
an
ou
tdo
or
po
we
red
wh
ee
lch
air
.
Po
siti
ve
eff
ect
s o
fw
he
elc
ha
ir f
ou
nd
.
35
. Pö
slet
al.
(200
7).
Psy
cho
me
tric
pro
pe
rtie
s o
fth
eW
HO
DA
S I
I in
reh
ab
ilit
ati
on
pa
tie
nts
.
Psy
cho
me
tric
qu
an
tita
tive
em
pir
ica
l st
ud
y
Ge
rma
ny
9
04
D
isa
bil
ity
an
dre
ha
bil
ita
tio
n
Va
lid
ati
on
of
the
Ge
rma
nve
rsio
n o
fth
e W
HO
DA
SII
.G
oo
d v
ali
dit
y a
nd
reli
ab
ilit
y a
nd
fact
ori
al
stru
ctu
re c
on
firm
ed
.
36
. Po
stet
al.
(20
08
). D
eve
lop
me
nt
an
d v
ali
da
tio
no
f IM
PA
CT
-S, a
nIC
F-b
ase
d q
ue
stio
nn
air
eto
me
asu
re a
ctiv
itie
s a
nd
pa
rtic
ipa
tio
n.
Psy
cho
me
tric
qu
an
tita
tive
em
pir
ica
l st
ud
y
Ne
the
rla
nd
s2
76
D
isa
bil
ity
an
dre
ha
bil
ita
tio
n
Va
lid
ati
on
of
the
IM
PA
CT
-S, a
n I
CF
-b
ase
d q
ue
stio
nn
air
e t
o m
ea
sure
act
ivit
ya
nd
pa
rtic
ipa
tio
n.
Go
od
co
ncu
rre
nt
va
lid
ity,
te
st-r
ete
st
reli
ab
ilit
y a
nd
inte
rna
lco
nsi
ste
ncy
.3
7. P
yn
e e
t al.
(20
03
). C
om
pa
rin
g t
he
S
en
siti
vit
y o
f G
en
eri
c E
ffect
ive
ne
ssM
ea
sure
s W
ith
Sy
mp
tom
Imp
rove
me
nt
inP
ers
on
s W
ith
Sch
izo
ph
ren
ia.
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
Un
ite
dS
tate
s1
34
M
ed
icin
eS
tud
yw
ith
co
nve
rge
nt
me
asu
res
on
the
se
nsi
tiv
ity o
fg
en
eri
c eff
ect
ive
ne
ss i
nim
pro
vin
gth
e s
ym
pto
ms
of
pe
op
le w
ith
sc
hiz
op
hre
nia
.
Co
nv
erg
en
t va
lid
ity
d
em
on
stra
ted
.
38
. Py
sze
let
al.
(20
06
). D
isa
bil
ity,
psy
cho
log
ica
l d
istr
ess
an
dq
ua
lity
of
life
in
bre
ast
can
cer
surv
ivo
rs w
ith
arm
ly
mp
he
de
ma
.
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
Po
lan
d1
00
0
Me
dic
ine
Ass
ess
me
nt
of
dis
ab
ilit
y,p
sych
olo
gic
al
dis
tre
ss a
nd
qu
ali
ty o
f li
fe i
nb
rea
stca
nce
r P
oli
sh s
urv
ivo
rs w
ith
arm
lym
ph
ed
em
a.
Co
rre
lati
on
s co
nfi
rme
d.
39
. Ro
thet
al.
(20
06
). S
lee
pP
rob
lem
s, C
om
orb
id M
en
tal
Dis
ord
ers
, an
d R
ole
Fu
nct
ion
ing
in
the
Nati
on
al
Co
mo
rbid
ity S
urv
ey
R
ep
lica
tio
n.
Ep
ide
mio
log
ica
lco
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
Un
ite
dS
tate
s9
28
2
Psy
chia
try
Na
tio
na
l su
rve
y o
n t
he
pre
va
len
ce o
fsl
ee
p d
iso
rde
rs, o
rth
e a
sso
cia
tio
ns
of
sle
ep
dis
ord
ers
wit
h r
ole
dis
ord
ers
rela
ted
to
co
mo
rbid
ity
of
me
nta
ld
iso
rde
rs.
Co
rre
lati
on
s co
nfi
rme
d.
40
. Sch
lote
et a
l.(2
00
8).
Use
of
the
W
HO
DA
S I
I w
ith
str
ok
e p
ati
en
tsa
nd
th
eir
re
lati
ve
s: r
eli
ab
ilit
y a
nd
in
ter-
rate
r-re
lia
bil
ity.
Psy
cho
me
tric
qu
an
tita
tive
em
pir
ica
l st
ud
y
Ge
rma
ny
1
68
D
isa
bil
ity
an
dre
ha
bil
ita
tio
n
Me
asu
rem
en
t o
fth
e r
eli
ab
ilit
y o
fW
HO
DA
S I
I w
ith
str
ok
e p
ati
en
ts a
nd
th
eir
re
lati
ve
s.
Go
od
re
lia
bil
ity.
41
. Sco
ttet
al.
(20
06
).D
isa
bil
ity
in
Te
Ra
u H
ine
ng
aro
:Th
e N
ew
Ze
ala
nd
Me
nta
l H
ea
lth
Su
rve
y.
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
New
Ze
ala
nd
12
99
2
Psy
chia
try
Stu
dy
on
rela
tio
nsh
ip b
etw
ee
nth
e
dis
ab
ilit
y a
nd
th
e p
rese
nce
of
me
nta
ld
iso
rde
rs a
nd
ch
ron
ic p
hy
sica
lco
nd
itio
ns
inth
e p
op
ula
tio
n o
fN
ew
Ze
ala
nd
, co
ntr
oll
ing
co
mo
rbid
ity,
ag
ea
nd
se
x.
Co
rre
lati
on
s id
en
tifi
ed
.
42
. Sco
ttet
al.
(20
08
).M
en
tal-
ph
ysi
cal co
-mo
rbid
ity
an
dit
sl
tih
iit
hd
ib
ilit
lt
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
New
Ze
ala
nd
69
7
Me
dic
ine
Su
rve
y o
n m
en
tal-
ph
ysi
calco
mo
rbid
ity
a
nd
on
its
rela
tio
nsh
ip w
ith
dis
ab
ilit
y.
Sm
all
co
rre
lati
on
ide
nti
fie
d.
96
Life Span and Disability Federici S. / Meloni F. / Lo Presti A.
fro
mth
e W
orl
d M
en
talH
ea
lth
Su
rve
ys.
43
. So
be
rget
al.
(20
07
). L
on
g-t
erm
mu
ltid
ime
nsi
on
al
fun
ctio
na
lco
nse
qu
en
ces
of
seve
re m
ult
iple
inju
rie
s tw
o y
ea
rsaft
er
tra
um
a: a
pro
spe
ctiv
e l
on
git
ud
ina
l co
ho
rtst
ud
y.
Pro
spe
ctiv
eq
ua
nti
tati
ve
em
pir
ica
l st
ud
y
No
rwa
y1
05
Me
dic
ine
Eva
lua
tio
n, t
hro
ug
hp
rosp
ect
ive
co
ho
rtst
ud
y,o
f th
e f
un
ctio
nin
g a
nd
qu
ali
ty o
fli
fe i
n p
ati
en
ts w
ith
seve
rem
ult
iple
inju
rie
s.
Co
rre
lati
on
id
en
tifi
ed
.
44
. Stu
cki
et a
l. (2
00
3).
Ass
ess
me
nt
of
the
im
pa
ct o
f d
ise
ase
on
th
e
ind
ivid
ua
l.
Rev
iew
of
self
-a
dm
inis
tere
dm
ea
sure
s o
n t
he
h
ea
lth
Ge
rma
ny
0
M
ed
icin
eIm
ple
me
nta
tio
no
f a
n a
lgo
rith
mfo
rth
e
sele
ctio
no
f cu
rre
nt
me
asu
res
for
the
a
sse
ssm
en
t o
f h
ea
lth
con
dit
ion
s.
Ab
ou
t th
e W
HO
DA
Sst
ate
s th
at
the v
ali
dit
ya
nd
re
lia
bil
ity
of
the
inst
rum
en
t a
re s
till
un
de
r in
ve
stig
ati
on
.4
5. U
lug
et a
l. (2
00
1).
Re
lia
bil
ity a
nd
va
lid
ity
of
the
Tu
rkis
h v
ers
ion
of
the
Wo
rld
He
alt
hO
rga
niz
ati
on
Dis
ab
ilit
y A
sse
ssm
en
tS
che
du
le-I
I (W
HO
-DA
S-I
I) i
n s
chiz
op
hre
nia
.
Psy
cho
me
tric
qu
an
tita
tive
em
pir
ica
l st
ud
y
Tu
rke
y
90
P
sych
iatr
yV
ali
da
tio
n o
fth
e T
urk
ish
ve
rsio
n o
fth
e W
HO
DA
S I
I in
pa
tie
nts
wit
h
sch
izo
ph
ren
ia.
Go
od
re
lia
bil
ity
an
dva
lid
ity.
46
. va
nT
ub
erg
en
et a
l. (2
003
).A
sse
ssm
en
t o
f d
isa
bil
ity
wit
h t
he
W
orl
d H
ea
lth
Org
an
isa
tio
nD
isa
bil
ity
Ass
ess
me
nt
Sch
ed
ule
II
in p
ati
en
tsw
ith
an
ky
losi
ng
spo
nd
yli
tis.
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
Ne
the
rla
nd
s2
14
Me
dic
ine
Co
nv
erg
en
t va
lid
ity
stu
dy
in
pa
tie
nts
wit
h a
nk
ylo
sin
g s
po
nd
yli
tis.
Co
nv
erg
en
t va
lid
ity
d
em
on
stra
ted
.
47
. Vá
zqu
ez-
Ba
rqu
ero
et a
l. (2
00
0).
Sp
an
ish
ve
rsio
n o
fth
e n
ew
Wo
rld
H
ea
lth
Org
an
izati
on
Dis
ab
lem
en
t A
sse
ssm
en
t S
che
du
le I
I.
Psy
cho
me
tric
qu
an
tita
tive
em
pir
ica
l st
ud
y
Sp
ain
16
3
Psy
chia
try
Va
lid
ati
on
of
the
Sp
an
ish
ve
rsio
no
fth
e W
HO
DA
SII
.G
oo
d v
ali
dit
y a
nd
reli
ab
ilit
y a
nd
fact
ori
al
stru
ctu
re c
on
firm
ed
.
48
. Vo
nK
orf
fet
al.
(20
05
).P
ote
nti
all
y M
od
ifia
ble
Fa
cto
rsA
sso
cia
ted
Wit
h D
isa
bil
ity
Am
on
gP
eo
ple
Wit
h D
iab
ete
s.
Co
rre
lati
on
al
qu
an
tita
tive
em
pir
ica
l st
ud
y
Un
ite
dS
tate
s4
35
7
Me
dic
ine
Ide
nti
fica
tio
no
f p
ote
nti
all
y m
od
ifia
ble
fact
ors
ass
oci
ate
dw
ith
dis
ab
ilit
y i
np
eo
ple
wit
h d
iab
ete
s.
Co
rre
lati
on
s id
en
tifi
ed
;id
en
tifi
cati
on
of
fact
ors
.
49
. Vo
nK
orf
fet
al.
(20
08
). M
od
ifie
dW
HO
DA
S-I
I p
rov
ide
s va
lid
me
asu
re o
f g
lob
al
dis
ab
ilit
y b
ut
filt
er
item
s in
cre
ase
d s
kew
ne
ss.
Psy
cho
me
tric
qu
an
tita
tive
em
pir
ica
l st
ud
y
Un
ite
dS
tate
s9
34
Me
dic
ine
Va
lid
ati
on
of
am
od
ifie
d v
ers
ion
of
the
WH
OD
AS
II w
ith
fil
ter
item
s.G
oo
d r
eli
ab
ilit
y a
nd
ge
ne
ral
va
lid
ity,
bu
tth
e
use
of
filt
er
qu
est
ion
sa
dve
rse
ly a
ffect
sth
e
pro
pe
rtie
s o
fth
ein
stru
me
nt.
50
. Wa
ng
et a
l. (2
006
).M
en
tal
he
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97
International Literature Rewiew on WHODAS II
51
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844
3. Review of international literature on the WHODAS II
Among the 54 studies identified by following the method describedabove, 51 are articles published in international journals, 2 were includedin the conferences and one is a dissertation. However, only seven articleswere published in journals or acts of conferences whose main object of in-terest is disability and rehabilitation (Federici, Scherer, Micangeli, Lom-bardo, & Olivetti Belardinelli, 2003; Annicchiarico, Gibert, Cortes, Cam-pana, & Caltagirone, 2004; Gallagher & Mulvany, 2004; Chisolm, Abrams,McArdle, Wilson, & Doyle, 2005; McArdle, Chisolm, Abrams, Wilson, &Doyle, 2005; Pettersson, Törnquist, & Ahlström, 2006; Federici, Meloni,Mancini, Lauriola, & Olivetti Belardinelli, 2009). The remaining workswere published in journals of medicine and psychiatry; the main purposeof these studies is the identification of correlations on comorbidity evalua-tions performed by clinicians about certain mental disorders. All thesestudies have investigated the correlation between the 6 domains of theWHODAS and/or its total score with the scores obtained on scales mea-suring depression (Alexopoulos, Raue, & Areán, 2003; Chwastiak & VonKorff, 2003; Kemmler et al., 2003; Kessler et al., 2003; McKibbin, Patterson,& Jeste, 2004;Yoon et al., 2004; Kim et al., 2005;Von Korff et al., 2005; Scott,McGee, Wells, & Browne, 2006; Banerjee et al., 2008), pain (Chwastiak &Von Korff, 2003; Stucki & Sigl, 2003; Pyszel, Malyszczak, Pyszel, Andrze-jak, & Szuba, 2006; Soberg, Bautz-Holter, Roise, & Finset, 2007), schizo-phrenia and psychotic disorders (Janca et al., 1996; Lastra et al., 2000; Ulug,Ertugrul, Gögüs, & Kabakçi, 2001; Pyne, Sullivan, Kaplan, & Williams,2003; Baumgartner, 2004; McKibbin et al., 2004; Norton, de Roquefeuil,Benjamins, Boulenger, & Mann, 2004; Mubarak, 2005; Chopra et al., 2008),quality of life (Goyal & Kulkarni, 2002; Kemmler et al., 2003; Pyne, Sulli-van, Kaplan, & Williams, 2003; Chopra, Couper, & Herrman, 2004; ES-EMeD/MHEDEA 2000 investigators, 2004; Donmez, Gokkoca, &Dedeoglu, 2005; Mubarak, 2005; Pyszel, Malyszczak, Pyszel, Andrzejak, &Szuba, 2006; Pösl, Miriam, Alarcos Cieza, & Gerold Stucki, 2007; Soberg,Bautz-Holter, Roise, & Finset, 2007; Baron et al., 2008; Hudson, Steele,Taillefer, & Baron, 2008; Hudson, Thombs, Steele, Watterson, Taillefer &Baron, 2008), sleep disorders (Roth et al., 2006), diabetes (Von Korff et al.,2005), ageing (Alexopoulos et al., 2003;Yoon et al., 2004; Kim et al., 2005;Donmez, Gokkoca & Dedeoglu, 2005), rheumatic disorders (Stucki & Sigl,2003; van Tubergen et al., 2003; Baron, Hudson, & Taillefer, 2005), anxietydisorders (Bonnewyn, Bruffaerts, Van Oyen, Demarest, & Demyttenaere,2005; Perini, Slade, & Andrews, 2006), strokes (Schlote et al., 2008), copingskills (Badr et al., 2007), cognitive functions (Kim et al., 2008), limitationsof activity and restrictions in participation (Post et al., 2008) or in epidemi-ological and comorbidity national and international surveys (Kessler et al.,2003; MaGPIe Research Group, 2003; ESEMeD/MHEDEA 2000 investi-
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gators, 2004; MaGPIe Research Group, 2004; Bonnewyn et al., 2005; Don-mez et al., 2005; Wang, Adair, & Patten, 2006; Buist-Bouwman et al., 2008;Scott et al., 2008).
The results obtained in these studies emphasize, first, that the WHODASII is a useful, reliable and valid tool for assessment of disability, functioningand social participation, and is sensitive to changes like the SF-36 (MedicalOutcomes Study Short Form 36); secondly, it facilitates the use of the ICF asa conceptual framework for the assessment of the limitations in activity andparticipation, and effectively discriminates between normal/healthy anddisabled/sick people (Ertugrul & Ulug, 2004). Some studies suggest to usingthe WHODAS II together with the SF-36 (Chwastiak & Von Korff, 2003;Pyne et al., 2003; Baron et al., 2005; Von Korff et al., 2005; Perini et al., 2006;Soberg et al., 2007) or with the WHO Quality of Life – short version(WHQOL-BREF) in order to improve the health profile (Goyal & Kulka-rni, 2002; Kemmler et al., 2003; Chopra et al., 2004) or together with CopingInventory for Stressful Situations (CISS) and Matching Person and Technol-ogy (MPT) to assess the individual coping strategies and the predisposi-tions to assistive technologies (Federici et al., 2003). Actually, the WHO-DAS II is a tool relatively complex and difficult to administer with full co-operation in psychiatric patients who reported that they were healthy anddenied “emotional or mental problems” as described in the WHODAS II(Chopra et al., 2004, p. 757).
Among the 51 articles, only eight have investigated the psychometricproperties of the WHODAS II (Vázquez-Barquero et al., 2000; Ulug et al.,2001; Yoon et al., 2004; Baron et al., 2005; Chisolm et al., 2005; Buist-Bouw-man et al., 2008; Von Korff et al., 2008; Federici et al., 2009) and one reportsthe translation into Spanish and its adaptation to the Latino culture(Matías-Carrelo et al., 2003).
Vázquez-Barquero and his/her collaborators (Vázquez-Barquero et al.,2000) have studied the development of the Spanish version of the WHO-DAS II through a pilot cross-cultural analysis with 54 Spanish, 50 Cubansand 59 Peruvians, male and female, adults. Factor analysis, analysis of re-dundancy and missing values were conducted. The scores of the modifiedversion of the instrument were compared with those of other countries.TheAuthors, however, failed to reach a clear and definitive assessment of thetool, merely to suggest further study on its psychometric properties.
Ulug et al. (2001) have assessed the reliability and validity of Turkishversion of the WHODAS II, in a study with 60 patients diagnosed withschizophrenia. The Cronbach’s Alpha, calculated for each of the six do-mains, reached values between .60 and .90, making possible to assess an ac-ceptable internal consistency of the instrument. Regarding construct valid-ity, domain scores displayed significant positive correlations with each oth-er as well as with the total DAS score. According to the Authors, therefore,the WHODAS II is able to distinguish patients from control subjects; in ad-
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dition, the results show that the Turkish version of the instrument has satis-factory requirements of validity and reliability.
The study of Yoon et al. (2004) was conducted to assess the Korean ver-sion of the WHODAS II, the sample consisted of 1204 elderly (aged 65years or over) South Korean, community residents. In this study the WHO-DAS II-K showed high levels of internal consistency and reliability (split-half, inter-rater and test-retest reliability). In the correlation analyses, scoreson the WHODAS II-K were significantly correlated with the unfavorableconditions in all variables on health condition and contextual factors. Par-tial correlations of scores on the WHODAS II-K with the health conditionwere significant even after controlling for contextual factors. Therefore, theconclusion of the authors is that the WHODAS II-K is a reliable and validinstrument for assessing disability in elderly population. More recently, apreliminary study of validity was conducted on 67 Canadian subjects suf-fering from scleroderma. (The title of the poster appears as substantiallyconfusing. We have attributed this to a misprint). The short abstract alsodoes not provide sufficient information for an assessment of the study.
Chisolm et al. (2005) examined the psychometric properties of the Eng-lish version of the WHODAS II, in a sample of 380 adults with hearing loss.The results of the analysis of convergent validity showed that the WHO-DAS II-E is correlated with the scores of the Abbreviated Profile of Hear-ing Aid Benefit (APHAB), the Hearing Aid Handicap for the Elderly(HHIE), and the SF-36 (short form). The internal consistency of scores indifferent domains was satisfactory, except for the domain “Interactions andrelationships with others”.
The test-retest stability was adequate for the scores of all domains.Buist-Bouwman et al., (2008) have assessed the factorial structure, the in-ternal consistency and the discriminant validity of the ESEMeD version ofthe WHODAS II, that is used in a European Study of Epidemiology ofMental Disorders.The sample was 8796 adults.The study confirms the struc-ture of six factors of the WHODAS II, finds a good internal consistency ofthe instrument and also the results of discriminant validity appear, on a pre-liminary analysis, as acceptable. Finally, Von Korff et al. (2008) consider thepsychometric properties of a WHODAS II modified for use in the WorldMental Health Surveys with the addition of filter items in different sub-scales. Internal consistency and validity of the modified WHODAS II aregenerally supported, but the use of filter questions impairs measurementproperties of the instrument.
The most comprehensive psychometric analysis conducted, to date, onthe WHODAS II is the work of Pösl et al. (2007), from a doctoral thesis, un-published, of M. Pösl (2004), under the direction of G. Stucki, University ofMonaco. The Authors evaluated the usefulness of the WHODAS II formeasuring functioning and disability in patients with musculoskeletal dis-eases, internal diseases, stroke, breast cancer, and depressive disorder. The
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Life Span and Disability Federici S. / Meloni F. / Lo Presti A.
validation of the German version of the WHODAS II was conducted in a sampleof 904 patients from 19 rehabilitation centers and clinics in Bavaria.There was,amongother things, a convergent validity with the SF-36.The conclusions of the study con-firm the structure of six domains of the WHODAS II; furthermore, the instrumentappears reliable and valid,and shows a sensitivity to change similar to that of the SF-36 in the corresponding subscales.
Given all the studies mentioned above, the WHODAS II was translatedinto the following languages: Italian (Federici et al., 2003;Annicchiarico et al.,2004; ESEMeD/MHEDEA 2000 investigators, 2004; Federici et al., 2009),English (Janca et al., 1996; Goyal & Kulkarni, 2002; Alexopoulos et al., 2003;Chwastiak & Von Korff, 2003; Kessler et al., 2003; MaGPIe Research Group,2003; Pyne J.M., Sullivan et al., 2003; Baumgartner, 2004; Chopra et al., 2004;ESEMeD/MHEDEA 2000 investigators, 2004; Gallagher & Mulvany, 2004;McKibbin et al., 2004; MaGPIe Research Group, 2004; Baron et al., 2005;Chisolm et al., 2005; McArdle et al., 2005; Mubarak, 2005; Von Korff et al.,2005; Perini et al., 2006; Roth et al., 2006; Scott et al. 2006; Wang et al., 2006;Baron et al., 2008; Hudson et al., 2008), Swedish (Pettersson et al., 2006),Dutch (van Tubergen et al., 2003; ESEMeD/MHEDEA 2000 investigators,2004;), German (Kemmler et al., 2003; Stucki & Sigl, 2003;ESEMeD/MHEDEA 2000 investigators, 2004; Pösl, 2007; Schlote et al.,2008), Korean (Yoon et al., 2004; Kim et al., 2005), Polish (Pyszel et al., 2006),Norwegian (Soberg et al., 2007), Turkish (Ulug et al., 2001; Ertugrul & Ulug,2004; Donmez et al., 2005), Spanish (Lastra et al., 2000; Vázquez-Barquero etal., 2000; Matías-Carrelo et al., 2003; ESEMeD/MHEDEA 2000 investigators,2004), French (Norton et al., 2004; ESEMeD/MHEDEA 2000 investigators,2004; Bonnewyn et al., 2005), Arabic (Badr et al., 2007). Korean, Polish andSwedish translations are not provided by WHO (WHO, 2004).
In conclusion, the review of international literature on the WHODASshows a broad consensus on the reliability and validity of the instrument, al-though the lack of standardized scores for the different translations of theWHODAS and the scarcity of particularly thorough studies does not guar-antee that the cultural and psychometric requirements have been met bythe instrument.
4. Characteristics of the Italian version of the WHODAS II
The study of Federici et al. had as general aim to provide a contributionto the validation of the Italian version of the WHODAS II, considering thewidespread consent about the usefulness of the tool. Specifically, the Au-thors wanted to test if the WHODAS II can be regarded as a reliable in-strument to assess the functioning and the self-perception of disability inpersons with normal abilities and disabled participants, by the means of theanalysis of some psychometric characteristics such as the reliability (inter-
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International Literature Rewiew on WHODAS II
nal homogeneity, Cronbach’s Alpha) and the validity (principal compo-nents analysis).
The Italian version of the WHODAS II has been adapted by the Authorsin the same format as the English one (36-Item Interviewer Administered,Day Codes Version – February 2000), because this was the most recent ver-sion of the instrument. The Authors have deleted the Italian items of thesections 3 and 5, since they were not further included in the last format ofthe English version.
The WHODAS II was administered to a sample of 500 participants (185males and 315 females,) divided into two sub-samples: 271 normal adultsand 229 disabled adults. Moreover, the disabled participant group com-prised 111 motor disabled, 45 mental disabled and 73 sensory disabled. Thefindings obtained show a good correspondence with the original structureof the WHODAS II. Furthermore, the internal consistency of most sub-scales, estimated by means of the Cronbach’s Alpha, was found to be highin the examined sample. Regarding the factorial structure of the instru-ment, the results confirm the presence of six main factors, according to thesix activity domains expected to be assessed by the WHODAS II.
The study of Federici et al. presents, however, some limitations: first, thethree subgroups of disabled do not match each other for participant num-ber, age and sex; moreover, the enrolment of mental disabled respondentsran into difficulties because it was not easy to access the centres for mentaldisabled in Italy. Finally, neither the convergent validity nor the reliabilitytest – re-test of the instrument- has been studied. A research prosecution istherefore desirable which proposes, among other things, achieving standardscores for each macro-category of disability. Normative scores of disabilitywould be useful to integrate the self-evaluation of a single individual re-garding his/her functioning in a specific context. Indeed, by comparing thedisability self-evaluation of a single individual to standard scores it will bepossible to assess how much each factor of the biopsychosocial determi-nants of the individual’s functioning influences the disability self-evaluationof that person.
5. Conclusions
The WHODAS II is a tool for the self-evaluation of limitations in activ-ities and restrictions in participation experienced by an individual, inde-pendently from a medical diagnosis. The self- evaluation of the instrumentappears a fundamental element compared to tests or questionnaires tradi-tionally used for the assessment of disability, which usually reveal the pointof view of the caregiver or clinician who compiles them. The revolution inthe conception of disability, functioning and health represented by the bio-psycho-social model and the new International Classification (ICF), con-
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ceptually compatible with it, reveals the absolute priority of an individualsubjective perspective, compared to any other etiopathological assessment,both the objective and reducing-individual-to-object point of view of theclinician.
The increasingly widespread utilization of the bio-psycho-social modelat international level and the simultaneous promotion of the use of the newclassification, have brought, in recent years, even increasing use of the newassessment tools, above all WHODAS II. This has involved, first, the needto accurately analyze the psychometric properties of the instrument, and inparticular its reliability, stability, internal consistency, convergent validityand factorial structure.
This study has reviewed all studies published (until 2008) in the majorscientific search engines, where has described the use and/or validation ofWHODAS II. Research conducted identified 54 studies: 51 articles in inter-national journals, 2 included in conferences and a doctoral dissertation. Ofthese, only six articles were published in journals or acts of conferenceswhose main object of interest is disability and rehabilitation. All studiesconsidered have assessed the degree of correlation between the scores ofthe WHODAS II and the scores obtained by subjects on rating scales relat-ed to: depression, pain, schizophrenia and other psychotic disorders, quali-ty of life, sleep disorders, diabetes, ageing , rheumatic disorders, anxiety dis-orders.All studies reviewed agree that the WHODAS II is an useful instru-ment for the assessment of disability, functioning and social participation,suggesting quite often to join the administration with scales used for mea-suring quality of life (eg.: SF-36 or WHQOL-BREF).Among the 51 articlesonly eight, however, have investigated the psychometric properties of theinstrument, concluding, almost unanimously, that the psychometric proper-ties of the WHODAS II allow it to be to considered a valid and reliable in-strument for the assessment of disability.
Among the main limitations that this review has helped to highlight, it isimportant to note that, to date, there are no standardized scores for the var-ious translations of the WHODAS and that the number of studies thatsought to investigate in detail the psychometric properties of the tool is par-ticularly limited. Therefore, it would be desirable not only to universalizethe tool, but also to deepen the studies conducted so far, in order to deter-mine more precisely the advantages and limitations of WHODAS II.
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