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International literature review on WHODAS II (World Health Organization Disability Assessment Schedule II)

Authors:
  • University of Perugia. Italy
Article

International literature review on WHODAS II (World Health Organization Disability Assessment Schedule II)

Abstract

This review is a critical analysis regarding the study and utilization of the World Health Organization Disability Assessment Schedule II (WHODAS II) as a basis for establishing specific criteria for evaluating relevant international scientific literature.The WHODAS II is an instrument developed by the World Health Organisation in order to assess behavioural limitations and restrictions related to an individual’s participation, independent from a medical diagnosis. This instrument was developed by the WHO’s Assessment, Classification and Epidemiology Group within the framework of the WHO/NIH Joint Project on Assessment and Classification of Disablements. To ascertain the international dissemination level of for WHODAS II’s utilization and, at the same time, analyse the studies regarding the psychometric validation of the WHODAS II translation and adaptation in other languages and geographical contests. Particularly, our goal is to highlight which psychometric features have been investigated, focusing on the factorial structure, the reliability, and the validity of this instrument. International literature was researched through the main data bases of indexed scientific production: the Cambridge Scientific Abstracts – CSA, PubMed, and Google Scholar, from 1990 through to December 2008.The following search terms were used:“whodas”, in the field query, plus “title” and “abstract”.The WHODAS II has been used in 54 studies, of which 51 articles are published in international journals, 2 conference abstracts, and one dissertation abstract. Nevertheless, only 7 articles are published in journals and conference proceedings regarding disability and rehabilitation. Others have been published in medical and psychiatric journals, with the aim of indentifying comorbidity correlations in clinical diagnosis concerning patients with mental illness. Just 8 out of 51 articles have studied the psychometric properties of the WHODAS II. The instruments have been translated into 11 languages and administered to a total of 88,844 subjects. Finally, the WHODAS II is prevalently used in the medical field, with major emphasis in the specialities of psychiatry, general medicine, and rehabilitation. All studies point out that WHODAS II as an effective and reliable instrument in order to assess the disability, individual functioning and participation levels. Furthermore, they often suggest administering the WHODAS II along with quality of life measures. Finally, the studies about the psychometric properties of the instrument agree in considering the WHODAS II a reliable and valid tool for disability assessment.
Abstract
This review is a critical analysis regarding the study and utilization of the
World Health Organization Disability Assessment Schedule II (WHO-
DAS II) as a basis for establishing specific criteria for evaluating relevant
international scientific literature.The WHODAS II is an instrument devel-
oped by the World Health Organisation in order to assess behavioural
limitations and restrictions related to an individual’s participation, inde-
pendent from a medical diagnosis.This instrument was developed by the
WHO’s Assessment, Classification and Epidemiology Group within the
framework of the WHO/NIH Joint Project on Assessment and Classifica-
tion of Disablements.
To ascertain the international dissemination level of for WHODAS II’s
utilization and, at the same time, analyse the studies regarding the psycho-
metric validation of the WHODAS II translation and adaptation in other
languages and geographical contests. Particularly, our goal is to highlight
which 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. The
following search terms were used:“whodas”, in the field query, plus “title”
and “abstract”.
1Department of Human and Educational Sciences,University of Perugia, Interdisciplinary
Research Centre on Disability and Technologies for Autonomy (CIRID) “Sapienza” Univer-
sity of Rome, e-mail: stefano.federici@unipg.it
2Ph.D. in Cognitive, Psycho-physiological, and Personality Psychology, Interuniversity
Center for Research on Cognitive Processing in Natural and Artificial System (ECONA) -
“Sapienza” University of Rome.
3Interdisciplinary 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,1Fabio 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 and
conference proceedings regarding disability and rehabilitation. Others
have been published in medical and psychiatric journals, with the aim of
indentifying 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 major
emphasis 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 the
psychometric 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 ICF
1.1.1. The ICIDH
Since 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 of
the consequences of disease. Since 1975 there has been in circulation, as an
internal document of the WHO, a version of the International Classification
of Impairments, Disabilities, and Handicaps (ICIDH). Subsequently, the
WHO requested Philip Wood to collect the material produced until then
and 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 and
terminology 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 health
point of view, a first-time distinction and definition of terms that,until then,
had been used interchangeably, creating considerable confusion among
health professionals.
The ICIDH proposes a tripartite distinction between Impairment, Dis-
ability and Handicap, defined as follows:
- Impairment: any loss, or abnormality, of psychological, physiological or
anatomical structures or functions.
- Disability: any limitation or loss (due to an impairment) of ability to
perform an activity or variations in the way considered normal for a human
being.
- Handicap: disadvantage experienced by a particular person, the result
of an impairment or a disability that limits or prevents the opportunity to
fill 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 result
of 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 produce
handicap. It is essential, according to the ICIDH, that the handicap is lived
or 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 model
of disability, and this is demonstrated by the substantial lack of aetiological
factors.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 cultural
context 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 disability
who 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 of
classification is defined in relation to a concept of normality that it is as-
sumed to be related primarily to biomedical categories.
85
International Literature Rewiew on WHODAS II
1.1.2. The ICF
In 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 review
process will certainly give an idea of the complexity of the problems dealt
with 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 and
causal, according to which disability (or/and handicap) is regarded as the
direct 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 are
described by using a negative terminology.
From an operative viewpoint, the main limitations characterising the
ICIDH were given by the use of terms which were inadequate with refer-
ence to the contemporary scientific context, as well as by the impossibility
to 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 is
abandoned in the ICF, to implement a circular interactive model in which
functioning and disability of a person are considered as the product of the
dynamic 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 and
Disability”; including the following components: a) body functions and
structures 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 the
units 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 by
operators 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 diverse
effects 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 state
of health which, in a given environment, becomes disabling, i.e. influencing
negatively on the person’s functioning abilities.
The ICF, wanting to describe functional states of each individual and
his/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 may
not be sufficient to explain the result of impairment.
Therefore, the disability is the complex and multiderminated outcome of
three main factors: the health of an individual, the personal and environ-
mental factors.The triadic reciprocal causation of factors exceeds the linear
etiological 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, is
certainly related to a state of health, conventionally regarded as pathologi-
cal, but not necessarily caused by the same condition as in the linear model
of the ICIDH.
The biopsychosocial model provides a perspective on the health concept
that is not always in line with the medical one.Since different environments
may have a very different impact on the same individual with a certain
health condition, like the ICF notes «two persons with the same disease
may 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 the
physiopathological, 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 one
has the advantage that it can be administered quickly and without special
training; the second one involves slightly longer times of administration and
requires specific training.
The Barthel Index (Mahoney & Barthel, 1965) is an ordinal scale with
total score from 0 (totally dependent) to 100 (totally independent) and
comprising 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, the
usual sources are direct questions to the patient, friends/relatives and nurs-
es, but also direct observation and common sense are important. Excellent
validity 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
87
International Literature Rewiew on WHODAS II
complex functions. Reflecting a background determined by the cultural
prevalence of the medical model, the Barthel index assigns an absolutely
relevant weight to functions such as continence or mobility and not the
least, also explores self-sufficiency in cognitive areas. Moreover, it is not a
real 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) measures
self-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 international
level, thanks to its wide distribution,the FIM is an instrument that assesses
the level of self-sufficiency of a person from the perspective of an outside
observer, leaving no space for self-evaluation.
1.3. The assessment of disability according to the biopsychosocial model
The direct application of the ICF and its codes appeared since the be-
ginning as a rather demanding and complex task: for this reason,the WHO
introduced the ICF Checklist (WHO, 2003), which allows the description of
the functioning profile of a subject based on 128 codes selected among the
thousands forming the whole ICF (in the second level there are already 362
codes, that become 1.424 in the third and fourth level) (ivi, p. 3). The ICF
checklist is not really an instrument for measure or assessment: its utility
comes 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 establish
whether, and in which measure, the environment acts either as barrier or
conversely facilitates the individual.
The ICF Checklist is administered to the patient or his/her caregiver. It
is structurally divided into four parts: the introductory part, which includes
biographical data, the ICD-10 code, and the specification of information
source; the first part,containing the list of codes of Body Functions (b) and
Body Structures (s); the second part, comprising the list of codes for Activ-
ities and Participation (d); and finally, the third part, containing the list of
codes 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 a
different 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 on
functioning and disability, the WHODAS II rates the nature of disability di-
rectly from the patient’s responses. Therefore, the ICF Checklist offers an
external (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 in
participation experienced by an individual, independently from a medical
diagnosis. 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), the
mode 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 form
administered by an interviewer for completeness.
The participants interviewed are asked to indicate the experienced level
of “difficulty” (none, mild, moderate, severe, extreme), by taking into account
the way in which they normally perform a given activity, and including the
use 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, in
terms of a 5-point ordinal scale: 1) Only one day; 2) Up to a week = from 2
to 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 with
his/her life.
Respondents should answer the questions according to the following
references:
1. Degree of difficulty (the increase in the effort, discomfort or pain, or
slowness, or differences in general);
2. Health conditions (disease or illness, or injury, or mental or emotional
problems, 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 the
WHODAS II at international level and in different fields of application
89
International Literature Rewiew on WHODAS II
Specifically, given the widespread consent universally reached about the
usefulness of the WHODAS II, we need to verify its reliability in assessing
the functioning and the self-perception of disability in persons with normal
abilities 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 next
paragraph, is intended to provide an overview, as complete as possible, of
scientific studies that have been made using the WHODAS II, since its pub-
lication until now. In most of these studies, moreover,the WHODAS II was
used in combination with other assessment tools: this has allowed us to ver-
ify its convergent validity, and its compatibility and complementarities with
these instruments.
A survey on the main databases of international indexed scientific pro-
duction, Cambridge Scientific Abstracts – CSA and PubMed, using as key
search the term “whodas” in the “title” and “abstract” field query, it was
found that the WHODAS II was used in 54 works. Table 1 shows the list
of 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 and
results.
90
Life Span and Disability Federici S. / Meloni F. / Lo Presti A.
91
International Literature Rewiew on WHODAS II
Articles published in international
journals
Type of study Nationality Subjects Area of
research
Purposes Results
1. Alexopoulos et al. (2003).
Problem-solving therapy versus
supportivetherapy in geriatric
major depressio n with executive
dysfunction.
Quantitative
empirical study
of clinical
treatment
United
States
25 Psychiatry Comparison of the effectiveness of
problem-solving therapy and
supportivecare in agroup of elderly
subjects with executive dysfunction.
Effectivene ss of
treatment for prob lem-
solving recognized.
2. Annicchiarico et al. (2004).
Qualitative prof iles of disab ilit y.
Qualitative
empirical study
Italy 96 Disability
and
rehabilitatio
n
Identification of profiles of functional
disab ility parallel to increased levels of
disability.
Identification of four
groups of individuals
with disabilities.
3. Badr et al. (2007). Role of Gender
in Coping Capabilities among
Young Visually Disabled Students.
Correlational
quantitative
empirical study
Egypt 200 Disability
and
rehabilitatio
n
Evaluation of the role of gender in
coping skills among yo ung visually
disabled students.
Correlation occurred.
4. Banerjee et al. (2008). Prevalence
of depressi on and its effect on
disability in patients with age-
related macular degeneration.
Correlational
quantitative
empirical study
India 53 Psychiatry Assessment of depression effects on
disability in patients with visual
macular degeneration.
Correlation occurred.
5. Baron et al. (2008). The clinimetric
properties of the world health
organization disability assessment
schedu le II in early inflammatory
arthritis.
Psychometric
quantitative
empirical study
Canada 172 Medicine Evaluation of clinimetric properties of
the WHODAS II in patients with early
inflammatory arthritis.
Good reliability and
validity.
6. Bonnewyn et al. (2005). The
impact of mental disorders on daily
functioning in the Belgian
communit y.
Epidemiological
correlational
quantitative
empirical study
Belgium 2419 Medicine Assessing the impact of mental
disorders on daily functioning of the
Belgian population.
Correlation occurred.
7. Buist-Bouwman et al. (2008).
Psychometric properties of the
Worl d Health Organization
Disabil ity Assessment Sched ule
used in the European Study of the
Epidemiology of Mental Disorders.
Psychometric
quantitative
empirical study
Netherlands 8796 Psychiatry Validation of the version of WHODAS
used in the European Study of the
Epidemiology of Mental Disorders
(ESEMeD).
Good reliability and
validity and factorial
structure confirmed.
8. Chisolm et al. (2005). The WHO-
DAS II: psychometric properties in
the measurement of functional
health status in adults with acquired
hearing loss.
Psychometric
quantitative
empirical study
United
States
380 Disability
and
rehabilitatio
n
Definition of the psychometric
properties of the WHODAS II for a
sample of adults with onset of hearing
loss.
Good reliability and
validity.
Tab. 1 - International literature on WHODAS II
92
Life Span and Disability Federici S. / Meloni F. / Lo Presti A.
9. Chopra et al. (2004). The
assessment of patients with lo ng-
term psychotic disorders:
Application of the WHO Disability
Assessment Sched ule II.
Psychometric
quantitative
empirical study
Australia 20 Psychiatry Evaluation of the WHODAS II in
patients treated for long-term psychotic
disorders.
Good reliability and
validity.
10. Chopra et al. (2008).
Comparison of disability and
quality of life measure s in patients
with long-term psychotic disorders
and patients with multiple sclerosis:
an application of the WHO
Disabil ity Assessment Schedule II
and WHO Qua lity of Life-BRE F.
Correlational
quantitative
empirical study
Australia 40 Psychiatry Comparison between the application of
the WHODAS II and the WHOQOL-
BREF in the evaluation of patients with
psychotic disorders and multiple
sclerosis.
Correlatio n confirmed.
11. Chwastiak et al. (2003).Disability
in depression and back pain:
evaluation of the World Health
Organizatio n Disability Assessment
Schedule (WHO DAS II) in a
primary care setting.
Psychometric
quantitative
empirical study
United
States
149 Medicine Evaluation of measurement properties
of the WHODAS II in two disorde rs
commonly encountered in primary care
setting.
Good validity and
responsiveness to
change.
12. Donmez et al. (2005). Disability
and its effects on qua lity of life
among older people living in
Antalya city center, Turkey.
Correlational
quantitative
empirical study
Turkey 840 Medicine Detection of frequency and severity
level of disability for older people
living in Antalya city center; evaluation
of the effects of disability and variables
associated with it on living conditions.
Frequency and severity
detected; correlation
detected.
13. Ertugrul et al. (2004). Perception
of stigma among patients with
schizophrenia.
Correlational
quantitative
empirical study
Turkey 60 Psychiatry Measurement of the relationship
between the symptoms and other
characteristics of schizophrenic patients
with self-perceived stigma.
Correlation occurred.
14. ESEMeD/MHEDEA 2000
investigators. (2004). Disability and
quality of life impact of mental
disorders in Europe.
Epidemiological
correlational
quantitative
empirical study
Belgium,
Germany,
Italy, Spain,
France an d
Netherlands
21425 Psychiatry Survey on the impact of the state of
mental health and specific mental and
physical disorders on work
performance and quality of life in six
Europea n countries.
Correlations occurred.
15. Federici et al. (2008). World
Health Organization Disability
Assessment Sched ule II (WHODAS
II): A contribution to the Italian
vali datio n.
Psychometric
quantitative
empirical study
Italy 500 Disability
and
rehabilitatio
n
Validation of the Italian version of the
WHODAS II.
Good validity and
relia bil ity and factorial
structure confirmed.
16. Gallagher et al. (2004). Levels of
ability and function ing: using the
WHODAS II in an Irish context
Correlational
quantitative
empirical study
Ireland 1304 Disability
and
rehabilitatio
Correlational analysis between socio-
demographic variables,causes of
disability and domains of individual
Correlations confirmed.
93
International Literature Rewiew on WHODAS II
the WHODAS II.
17. Goyal et al. (2002). Efficacy of
Menosan, a polyherbal formulation
in the management ofmenopausal
syndr ome with respect to quality of
life.
Correlational
quantitative
empirical study
India 40 Medicine Assessment of the effects ofMenosan, a
polyherbal formulation, on quality of
life in menopausal women.
Correlation confirmed;
efficacy of Menosan
demonstrated.
18. Hudson et al. (2008). Clinical
correlates of quality of life in
systemic sclerosis measured with the
Worl d Health Organization
Disabil ity Assessment Schedule II.
Correlational
quantitative
empirical study
Canada 337 Medicine Identification of clinical features of
systemic sclerosis that best correlate
with the quality of life related to the
health of patients.
Clinical correlates
identified.
19. Hudson et al. (2008). Quality of
life in systemic sclerosis:
psychometric properties of the
Worl d Health Organization
Disabil ity Assessment Schedule II.
Psychometric
quantitative
empirical study
Canada 402 Medicine Study of validity of theWHODAS II in
patients with systemic sclerosis.
Good validity.
20. Janca et al. (1996). The World
Health Organization Short
Disabil ity Assessment Sched ule
(WHO DAS-S): atool for the
assessment of difficulties in selected
areas of functioning of patients with
mental disorders.
Analytical study Switzerlan d 0 Psychiatry
and medicine
Study of characteristics of the
WHODAS-S as a clinica l tool for
evaluation of individual functioning in
psychiatric subjects.
Detection of agood
utility and ease of use
and acceptab le
reliability for use by
clinicians be lon gin g to
different schools and
psychiatric traditions.
21. Kemmler et al. (2003). Quality of
life of HIV-infected patients:
Psychometric properties and
vali datio n of the German versio n of
the MQOL-HI V.
Psychometric
quantitative
empirical study
Germany 207 Medicine Convergent validity study of the
German versio n of the
Multidimensional Quality of Life
Questionnaire for HIV/AIDS on a
sample of HIV-infected patients.
Good validity and
reliability of the
Multidimensional
Quality of Life
Questionnaire for
HIV/AIDS; convergent
validity demonstrated.
22. Kessler et al. (2003). The
Epidemiology of Major Depressive
Disorder: Results from the; National
Comorbidity Survey Replication
(NCS-R).
Epidemiological
correlational
quantitative
empirical study
United
States
9090 Medicine Survey on prevalence,correlation and
clinical relevance ofthe DSM disorders
and assessment of treatments adequacy.
Prevalence, correlates
and clinical relevance
identified; inadequacy
of treatment detected.
23. Kimet al. (2005). Physical health,
depression and cognitive function
as correlates of disab ility in an older
Korean population.
Correlational
quantitative
empirical study
South
Korea
1204 Psychiatry Survey on independent associations
between physical health, depression,
cognitive function and disability in the
older Korean population.
Correlations confirmed.
24. Kimet al. (2008). BDNF
t t ti ll dif i th
Correlational
quantitative
South
Korea
500 Psychiatry Survey on the role of a genotype
(val66met)of the neurotrophic factor
Correlatio n confirmed.
94
Life Span and Disability Federici S. / Meloni F. / Lo Presti A.
association between incident stroke
and depression.
empirical study derived from the brain (BDNF) in the
association between stroke and
depression.
25. Lastra et al. (2000). The
classification of first episode
schizophrenia: a cluster-analytical
approach.
Qualitative
empirical study
Spain 86 Psychiatry Check the classification of a
schizophrenic population into
subgroups for similar symptoms
profiles.
Divisio n into
subgroups confirmed,
but not pred ictive.
26. MaGPIe Research Group.
(2004). General practitioner
recognition of mental illness in the
absence of a ‘gold standard’.
Correlational
quantitative
empirical study
New
Zealand
845 Psychiatry Compariso n between the general
practice of recognition of mental illness
and thecases identified by diagnostic
instrume nts and screening.
Correlation is not
verified; variability
between instruments
and between clinical
opinion and screening
and diagn ost ic tests.
27. MaGPIe Research Group.
(2003). The nature and prevalence
of psychological problems in New
Zealand primary healthcare: a
report on Mental Health and
Genera l Practice Investigation
(MaGPIe).
Correlational
quantitative
empirical study
New
Zealand
70 Medicine Study of the degree of disability and
other factors that influence the
recognition, management,course and
outcome of mental disorders in patients
of New Zealand.
Correlations confirmed.
28. Matías-Carrelo et al. (2003). The
Spanish translation and cultural
adaptation of five mental health
outcome measures.
Qualitative
empirical study
of translation
and adaptation
Spain 130 Medicine Spanish translation and adaptation of
five measures of mental health.
Semantic, technicaland
content equivalence
demonstrated.
29. McArdle et al. (2005). The WHO-
DAS II: measurin g outcomes of
hearing aid interventio n for adults.
Correlational
quantitative
empirical study
United
States
380 Disability
and
rehabilitatio
n
Assessment of reactivity ofthe
WHODAS II to the short and long term
effects in applications of acoustic
devices.
Good reactivity of the
WHODAS II,
correlation detected.
30. McKibbin et al. (2004). Assessing
Disability in Older Patients With
Schizophrenia Results From the
WHODAS-II.
Psychometric
quantitative
empirical study
United
States
76 Medicine Evaluation of reliability and validity of
the WHODAS II in older patients with
schizophrenia.
Strong evidence of
good reliability and
some evidence of good
validity.
31. Mubarak AR. (2005). Social
functioning and quality of life of
people with schizophrenia in the
northern regio n of Malaysia.
Correlational
quantitative
empirical study
Malaysia 258 Medicine Investigation on the relationship
between social functioning and quality
of life of people with schizop hrenia in
Malaysia.
Correlatio n confirmed.
32. Norton et al. (2004). Psychiatric
morbidity, disability and serv ice use
amongst primary care attenders in
France.
Correlational
quantitative
empirical study
France 124 Psychiatry Investigation on the relationship
between psychiatric morbidity,
disab ility and use of services in French
patients.
Correlations confirmed.
33. Perini et al. (2006). Generic
effectiveness measures: Se nsitivity to
Correlational
quantitative
Australia 169 Medicine Study with convergent measures on
sensitivity to change in people with
Convergent validity
demonstrated
95
International Literature Rewiew on WHODAS II
disorders.
34. Pettersson et al. (2006).The effect
of an outdo or powered wheelchair
on activity and participation in users
with stroke.
Quantitative and
longitudinal
empirical study
Sweden 32 Disability
and
rehabilitatio
n
Self-evaluation of the limitations in
activities and restrictions in the
participation of people with stroke,
before and after the use of an outdoor
powered whee lchair.
Posit ive effects of
wheelchair found.
35. Pösl et al. (2007). Psychometric
properties of the WHODAS II in
rehabilitation patients.
Psychometric
quantitative
empirical study
Germany 904 Disability
and
rehabilitatio
n
Validation of the German version of
the WHODAS II.
Good validity and
relia bil ity and factorial
structure confirmed.
36. Post et al. (2008). Development
and validation of IMPACT-S, an
ICF-based questionn aire to
measure activities and participation.
Psychometric
quantitative
empirical study
Netherlands 276 Disability
and
rehabilitatio
n
Validatio n of the IMPACT-S, an ICF-
based q uestionnaire to measure activity
and participation.
Good concurrent
vali dit y, test-retest
reliability and internal
consistency.
37. Pyne et al. (2003). Comparing the
Sen sitivity of Generic Effectivene ss
Measures With Sympt om
Improvement in Persons With
Schizophrenia.
Correlational
quantitative
empirical study
United
States
134 Medicine Study with convergent measures on the
sens itivity of generic effectiveness in
improvi ng the symptoms of people with
schizophrenia.
Convergent validity
demonstrated.
38. Pyszel et al. (2006). Disability,
psychological distress and quality of
life in breast cancer survivors with
arm lymphedema.
Correlational
quantitative
empirical study
Poland 1000 Medicine Assessment of disability, psychological
distress and qua lity of life in breast
cancer Polish survivo rs with arm
lymphedema.
Correlations confirmed.
39. Roth et al. (2006). Sleep
Problems, Comorbid Mental
Disorde rs, and Role Functioning in
the National Comorbidity Survey
Replication.
Epidemiological
correlational
quantitative
empirical study
United
States
9282 Psychiatry National survey on the prevalence of
sleep disorders, or the associations of
sleep disorders with role disorders
related to comorbidity of mental
disorders.
Correlations confirmed.
40. Schlote et al. (2008). Use of the
WHODAS II with stroke patients
and their relatives: reliabil ity and
inter-rater-reliability.
Psychometric
quantitative
empirical study
Germany 168 Disability
and
rehabilitatio
n
Measurement of the reliability of
WHODAS II with stroke patients and
their relatives.
Good reliability.
41. Scottet al. (2006).Disability in Te
Rau Hinengaro: The New Zealand
Mental Health Survey.
Correlational
quantitative
empirical study
New
Zealand
12992 Psychiatry Study on relationsh ip between the
disability and the presence of mental
disorders and chronic physical
conditions in the population ofNew
Zealand, controlling comorbidity,age
and sex.
Correlations identified.
42. Scottet al. (2008).Mental-
physical co-morbidity and its
l ti hi ith di bilit lt
Correlational
quantitative
e
m
p
iri
ca
l
study
New
Zealand
697 Medicine Survey on mental-physical comorbidity
andonits relationship with disability.
Small correlation
identified.
96
Life Span and Disability Federici S. / Meloni F. / Lo Presti A.
from the World Mental Health
Surveys.
43. Soberg et al. (2007). Long-term
multidimensional functional
consequences of severe multiple
injuries two years after trauma: a
prospective longitudinal cohort
study.
Prospective
quantitative
empirical study
Norway 105 Medicine Evaluation, through prospective cohort
study, of the functioning and quality of
life in patients with severe multiple
injuries.
Correlation identified.
44. Stucki et al. (2003). Assessment of
the impact of disease on the
individual.
Review of self-
administered
measures on the
health
Germany 0 Medicine Implementation of an algorithm for the
selection of current measures for the
assessment of health conditions.
About the WHODAS
states that the validity
and reliability of the
instrument are still
under investigation.
45. Ulug et al. (2001). Reliabil ity and
validity of the Turkish versio n of
the World Health Organization
Disabil ity Assessment Sched ule-II
(WHO-DAS-II) in schizop hrenia.
Psychometric
quantitative
empirical study
Turkey 90 Psychiatry Validation of the Turkis h version of
the WHODAS II in patients with
schizophrenia.
Good reliability and
validity.
46. van Tubergen et al. (2003).
Assessment of disability with the
World Health Organisation
Disabil ity Assessment Schedule II
in patients with ankylosing
spondylitis.
Correlational
quantitative
empirical study
Netherlands 214 Medicine Convergent validity study in patients
with ankylosing spondylitis.
Convergent validity
demonstrated.
47. Vázquez-Barquero et al. (2000).
Spanish versi on of the new World
Health Organization Disablement
Assessment Schedule II.
Psychometric
quantitative
empirical study
Spain 163 Psychiatry Validation of the Spanish version of
the WHODAS II.
Good validity and
relia bil ity and factorial
structure confirmed.
48. Von Korff et al. (2005).
Potentially Modif iable Factors
Associated With Disability Among
People With Diabetes.
Correlational
quantitative
empirical study
United
States
4357 Medicine Identification of potentially modifiable
factors associated with disabil ity in
people with diabetes.
Correlations identified ;
identification of factors.
49. Von Korff et al. (2008). Modified
WHODAS-II provides valid
measure of global disability but
filter items increased s kewness.
Psychometric
quantitative
empirical study
United
States
934 Medicine Validation of a modified version of the
WHODAS II with filter items.
Good reliability and
general validit y, but the
use offilter questions
adversely affects the
properties of the
instrument.
50. Wang et al. (2006).Mental health
and related disability among
workers: A po pulation-based stud y.
Correlational
quantitative
empirical study
Canada 5383 Medicine Survey on the prevalence of psychiatric
syndromes and related disability in a
population of adult workers.
Prevalence and
correlations identified.
97
International Literature Rewiew on WHODAS II
51. Yoo n et al. (2004). Development
of Korean version of World Health
Organizatio n Disability Assessment
Schedule II (WHODAS II-K) in
Community Dwelling Elders.
Psychometric
quantitative
empirical study
Korea 1204 Neuropsychi
atry
Validatio n of the Korean version of the
WHODAS II with elderly subjects.
Good validity and
relia bil ity and factorial
structure confirmed.
Subtotal of subjects 88332
Studies included in conferences Type of study Nationality Subjects Area of
research
Purposes Results
1. Baron et al. (2005). Preliminary
study of the validity of the World
Health Organization Disease
Assessment Schedule (WHODAS
II) in patients with sclerode rma.
Psychometric
quantitative
empirical study
Canada 67 Medicine Study on psychometriccharacteristics
of the WHODAS II in patients with
scleroderma.
Good validity.
2. Federici et al. (2003).A Cross-
CulturalAnalysis of Relationships
between Disability Self-Evaluation
and Individual Predisposition to
Use Assistive Technolog y.
Correlational
quantitative
empirical study
Italy and
United
States
200 Disability
and
rehabilitatio
n
Study on correlation between disability
self-evaluation, individual coping
strategies and individual
predisposition to the use of assistive
technologies.
Correlations identified.
Subtotal of subjects 267
Dissertations Type of study Nationality Subjects Area of
research
Purposes Results
1. Baumgartner J.N. (2004).
Measuring disab ility and social
integration among adults with
psychotic disorders in Dar es
Sa laam , Ta nzan ia.
Correlational
quantitative
and qualitative
empirical study
Tanzania 245 Psychiatry Study on the relationship between the
severity of self-perceived d isability and
indicators of social integration (marital
status, fertility and employment) in
adult patients with psychotic disorders
in Tanzania.
Correlatio n confirmed
between severity of self-
perceived disability and
one indicator of social
integration: the
employment.
Total of subjects 88844
3. Review of international literature on the WHODAS II
Among the 54 studies identified by following the method described
above, 51 are articles published in international journals, 2 were included
in the conferences and one is a dissertation. However, only seven articles
were 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 works
were published in journals of medicine and psychiatry; the main purpose
of these studies is the identification of correlations on comorbidity evalua-
tions performed by clinicians about certain mental disorders. All these
studies have investigated the correlation between the 6 domains of the
WHODAS and/or its total score with the scores obtained on scales mea-
suring depression (Alexopoulos, Raue, & Areán, 2003; Chwastiak & Von
Korff, 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), anxiety
disorders (Bonnewyn, Bruffaerts, Van Oyen, Demarest, & Demyttenaere,
2005; Perini, Slade, & Andrews, 2006), strokes (Schlote et al., 2008), coping
skills (Badr et al., 2007), cognitive functions (Kim et al., 2008), limitations
of 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-
98
Life Span and Disability Federici S. / Meloni F. / Lo Presti A.
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 WHODAS
II is a useful, reliable and valid tool for assessment of disability, functioning
and social participation, and is sensitive to changes like the SF-36 (Medical
Outcomes Study Short Form 36);secondly,it facilitates the use of the ICF as
a conceptual framework for the assessment of the limitations in activity and
participation, and effectively discriminates between normal/healthy and
disabled/sick people (Ertugrul & Ulug,2004). Some studies suggest to using
the 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 Coping
Inventory 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 and
denied “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 psychometric
properties 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 reports
the 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 Cubans
and 59 Peruvians, male and female, adults. Factor analysis, analysis of re-
dundancy and missing values were conducted. The scores of the modified
version of the instrument were compared with those of other countries.The
Authors, however, failed to reach a clear and definitive assessment of the
tool, merely to suggest further study on its psychometric properties.
Ulug et al. (2001) have assessed the reliability and validity of Turkish
version of the WHODAS II, in a study with 60 patients diagnosed with
schizophrenia. 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-
99
International Literature Rewiew on WHODAS II
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 65
years 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, scores
on the WHODAS II-K were significantly correlated with the unfavorable
conditions in all variables on health condition and contextual factors. Par-
tial correlations of scores on the WHODAS II-K with the health condition
were significant even after controlling for contextual factors.Therefore, the
conclusion of the authors is that the WHODAS II-K is a reliable and valid
instrument for assessing disability in elderly population. More recently, a
preliminary study of validity was conducted on 67 Canadian subjects suf-
fering from scleroderma. (The title of the poster appears as substantially
confusing. We have attributed this to a misprint).The short abstract also
does 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 in
different domains was satisfactory, except for the domain “Interactions and
relationships 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 of
the WHODAS II, that is used in a European Study of Epidemiology of
Mental Disorders.The sample was 8796 adults.The study confirms the struc-
ture of six factors of the WHODAS II, finds a good internal consistency of
the instrument and also the results of discriminant validity appear,on a pre-
liminary analysis,as acceptable. Finally,Von Korff et al. (2008) consider the
psychometric properties of a WHODAS II modified for use in the World
Mental Health Surveys with the addition of filter items in different sub-
scales. Internal consistency and validity of the modified WHODAS II are
generally supported, but the use of filter questions impairs measurement
properties of the instrument.
The most comprehensive psychometric analysis conducted, to date, on
the 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 of
Monaco. The Authors evaluated the usefulness of the WHODAS II for
measuring functioning and disability in patients with musculoskeletal dis-
eases, internal diseases, stroke, breast cancer, and depressive disorder. The
100
Life Span and Disability Federici S. / Meloni F. / Lo Presti A.
validation of the German version of the WHODAS II was conducted in a sample
of 904 patients from 19 rehabilitation centers and clinics in Bavaria.There was,among
other 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 instrument
appears 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 translated
into 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 et
al., 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 and
Swedish translations are not provided by WHO (WHO, 2004).
In conclusion, the review of international literature on the WHODAS
shows a broad consensus on the reliability and validity of the instrument, al-
though the lack of standardized scores for the different translations of the
WHODAS and the scarcity of particularly thorough studies does not guar-
antee that the cultural and psychometric requirements have been met by
the instrument.
4. Characteristics of the Italian version of the WHODAS II
The study of Federici et al. had as general aim to provide a contribution
to the validation of the Italian version of the WHODAS II, considering the
widespread 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 in
persons with normal abilities and disabled participants,by the means of the
analysis of some psychometric characteristics such as the reliability (inter-
101
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 Authors
in 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 the
sections 3 and 5, since they were not further included in the last format of
the English version.
The WHODAS II was administered to a sample of 500 participants (185
males and 315 females,) divided into two sub-samples: 271 normal adults
and 229 disabled adults. Moreover, the disabled participant group com-
prised 111 motor disabled, 45 mental disabled and 73 sensory disabled.The
findings obtained show a good correspondence with the original structure
of the WHODAS II. Furthermore, the internal consistency of most sub-
scales, estimated by means of the Cronbach’s Alpha, was found to be high
in the examined sample. Regarding the factorial structure of the instru-
ment, the results confirm the presence of six main factors, according to the
six activity domains expected to be assessed by the WHODAS II.
The study of Federici et al. presents, however, some limitations: first,the
three subgroups of disabled do not match each other for participant num-
ber, age and sex; moreover, the enrolment of mental disabled respondents
ran into difficulties because it was not easy to access the centres for mental
disabled in Italy. Finally, neither the convergent validity nor the reliability
test – re-test of the instrument- has been studied.A research prosecution is
therefore desirable which proposes,among other things,achieving standard
scores for each macro-category of disability. Normative scores of disability
would be useful to integrate the self-evaluation of a single individual re-
garding his/her functioning in a specific context. Indeed, by comparing the
disability self-evaluation of a single individual to standard scores it will be
possible to assess how much each factor of the biopsychosocial determi-
nants of the individual’s functioning influences the disability self-evaluation
of 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 instrument
appears a fundamental element compared to tests or questionnaires tradi-
tionally used for the assessment of disability, which usually reveal the point
of view of the caregiver or clinician who compiles them. The revolution in
the conception of disability, functioning and health represented by the bio-
psycho-social model and the new International Classification (ICF), con-
102
Life Span and Disability Federici S. / Meloni F. / Lo Presti A.
ceptually compatible with it, reveals the absolute priority of an individual
subjective perspective, compared to any other etiopathological assessment,
both the objective and reducing-individual-to-object point of view of the
clinician.
The increasingly widespread utilization of the bio-psycho-social model
at international level and the simultaneous promotion of the use of the new
classification, have brought, in recent years, even increasing use of the new
assessment tools, above all WHODAS II. This has involved, first, the need
to accurately analyze the psychometric properties of the instrument, and in
particular its reliability, stability, internal consistency, convergent validity
and factorial structure.
This study has reviewed all studies published (until 2008) in the major
scientific search engines, where has described the use and/or validation of
WHODAS II. Research conducted identified 54 studies: 51 articles in inter-
national journals, 2 included in conferences and a doctoral dissertation. Of
these, only six articles were published in journals or acts of conferences
whose main object of interest is disability and rehabilitation. All studies
considered have assessed the degree of correlation between the scores of
the 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 articles
only eight, however, have investigated the psychometric properties of the
instrument, 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 is
important to note that, to date, there are no standardized scores for the var-
ious translations of the WHODAS and that the number of studies that
sought to investigate in detail the psychometric properties of the tool is par-
ticularly limited. Therefore, it would be desirable not only to universalize
the tool, but also to deepen the studies conducted so far, in order to deter-
mine more precisely the advantages and limitations of WHODAS II.
103
International Literature Rewiew on WHODAS II
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... Even though it has been much improved and modified over the years, ADL BI cognitive dimension still requires additional investigations. 7 In order to address this, the WHO published the World Health Organization Disability Assessment Schedule (WHODAS), a tool adapted within the Italian setting in the year 2010, and based on the ICF; WHODAS 2.0. WHODAS 2.0 assesses the nature of disability from an individual's responses and self-perception, considering individuals with normal activity and disabilities. ...
... 8 This tool was designed to evaluate the behavioral limitations and restrictions of an individual to function and participate, regardless of the medical diagnosis. 7 Both ADL BI and WHODAS 2.0 have been translated in Italian, validated for Italian language, 9,10 and applied in numerous specialized settings, not only mental health and psychiatry, cardiovascular and cardiac, but also neurological fields. [11][12][13][14][15][16][17][18][19][20][21][22][23] However, despite the relevance of the topic, available scientific evidence shows few implementations of these tools within the rehabilitation context. ...
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Purpose: The aim of the present study was to compare 2 clinical assessment tools, the Modified Barthel Index (currently administered to patients admitted into inpatient rehabilitation units after elective hip or knee arthroplasty) with the World Health Organization Disability Assessment Schedule (WHODAS) 2.0 scale, in order to identify which tool is more suitable for assessing the disability and the “recovery rate”. Patients and methods: A perspective multicenter observational study was developed, involving 2 hospital authorities in Italy. Eighty consecutive cases of inpatients were enrolled. Patient’s disability was evaluated using both of the aforementioned tools, before and after the rehabilitation program. Results: The WHODAS 2.0 score was, on average, 12.21% higher than the Modified Barthel Index, before the surgical intervention. Modified Barthel Index measures could be considered as a determinant and a predictor of length of stay. Conclusion: The Modified Barthel Index is limited, since it does not consider a patient’s perspective. The WHODAS 2.0 scale fully considers a patient’s perception of disability. Therefore, both assessment scales should be administered in clinical practice, in order to provide integration of clinical information with a patient’s reported outcome measures.
... Health Organization Disability Assessment Schedule II (WHO-DAS II) was developed building on the theoretical models described and recommended by the 2001 International Classification of Functioning, Disability and Health, regarding the general evaluation and measurement of health conditions, disabilities, and psychometric variables [43]. The WHO-DAS II provides a standardized cross-cultural method for measuring the health and disability status of adults (aged over 18 years) over a 30-day period and contains 32 items covering six domains: cognition, mobility, self-care, getting along with people, activities of daily life, and social participation [44]. Scores are classified into five levels: no difficulty, mild difficulty, moderate difficulty, severe difficulty, and extreme difficulty [45]. ...
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Background Total hip arthroplasty (THA) is a common and effective surgical method for advanced hip arthritis. Rehabilitation exercises are important to improve joint function after THA and are usually conducted in a home-based program. Poor patient adherence limits improvements in pain and function, affecting quality of life. The increasing use of THA in the aging Chinese population underscores the need to develop strategies that maximize functional outcomes. The purpose of this pilot study is to develop and assess the feasibility of a self-efficacy-enhancing intervention (SEEI) to improve exercise adherence in patients undergoing THA. Methods This single-blinded, parallel, randomized control trial will recruit 150 patients after THA and randomly assign them to an intervention or control group using computer-generated block randomization. The control group will receive usual care using evidence-based guidelines. The intervention group will receive the 6-month SEEI comprising personalized exercise guidance and self-efficacy education delivered using one face-to-face education session and four telephone consultations, supplemented by written materials. Participants are encouraged to build confidence in their own abilities, set rehabilitation goals, and self-monitor their physical exercise. Results Assessments will be conducted at baseline and 1, 3, and 6 months postsurgery. The outcome indicators are exercise adherence, physical function, anxiety and depression, self-efficacy of rehabilitation, joint function, and quality of life. Conclusions This study will test a theory-based intervention program to improve self-efficacy in rehabilitation, which may significantly impact out-of-hospital rehabilitation. The results will provide evidence to inform the postoperative recovery of patients undergoing THA or similar procedures. Trial registration Chinese Clinical Trials Registry, ChiCTR2000029422, registered on 31 January 2020
... The World Health Organization Disability Assessment Schedule II (WHO-DAS II) was developed based on the concepts and theoretical models of the 2001 International Classi cation of Functioning, Disability and Health, regarding the general evaluation and measurement of health conditions, disabilities, and psychometric variables [44]. The WHO-DAS II provides a standardized cross-cultural method for measuring the health and disability status of adults (aged over 18 years) over a 30-day period and contains 32 items covering six domains: cognition, mobility, self-care, getting along with people, activities of daily life, and social participation [45]. Scores are classi ed into ve levels: no di culty, mild di culty, moderate di culty, severe di culty, and extreme di culty [46]. ...
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Full-text available
Background: Total hip arthroplasty (THA) is a common and effective surgical method for advanced hip arthritis. Rehabilitation exercises are important to improve joint function after THA and are usually conducted in a home-based program. Poor patient adherence limits improvements in pain and function, affecting quality of life. The increasing use of THA in the aging Chinese population underscores the need to develop strategies that maximize functional outcomes. The purpose of this pilot study is to develop and assess the feasibility of a self-efficacy-enhancing intervention (SEEI) to improve exercise adherence in patients undergoing THA. Methods: This single-blinded, parallel, randomized control trial will recruit 150 patients after THA and randomly assign them to an intervention or control group using computer-generated block randomization. The control group will receive usual care using evidence-based guidelines. The intervention group will receive the 6-month SEEI comprising personalized exercise guidance and self-efficacy education delivered using one face-to-face education session and four telephone consultations, supplemented by written materials. Participants are encouraged to build confidence in their own abilities, set rehabilitation goals, and self-monitor their physical exercise. Results: Assessments will be conducted at baseline, and 1, 3, and 6 months postsurgery. The outcome indicators are exercise adherence, physical function, anxiety and depression, self-efficacy of rehabilitation, joint function, and quality of life. Conclusions: This study will test a theory-based intervention program to improve self-efficacy in rehabilitation, which may significantly impact out-of-hospital rehabilitation. The results will provide evidence to inform the postoperative recovery of patients undergoing THA or similar procedures. Trial registration: Chinese Clinical Trials Registry (ChiCTR2000029422), registered 31 January 2020.
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... Using the IRT-based scoring, the scores were converted into a metric, ranging from 0 (no disability) to 100 (full disability) (WHO, 2010). The WHODAS 2.0 demonstrated good reliability and validity, and a factor structure that has proved consistent across cultures and patient populations (Federici, Meloni, & Presti, 2009;WHO, 2010). The WHODAS 2.0 defines disability according to the ICF (WHO, 2010). ...
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The aim of the present study was to examine the influence of disability on changes in symptoms of PTSD, anxiety, and depression among treatment-seeking traumatized refugees. Eighty-one refugees participated in different rehabilitation programs. PTSD symptomatology was assessed by the HTQ-IV and symptoms of depression and anxiety were assessed by the HSCL-25. Disability was assessed by the WHODAS 2.0 before treatment. Following treatment, no statistically significant changes in PTSD, depression, and anxiety symptom scores were observed. Disability in the domain ‘getting along’ was a significant predictor of PTSD scores following treatment, when controlling for baseline scores. Neither total disability nor individual disability domains predicted any other symptom changes. Living with one’s partner did, however, seem to be a consistent and significant predictor of treatment outcome. The results are discussed in terms of clinical implications and future research needs.
... An environment with or without barriers can limit or facilitate the individual performance (World Health Organization, 2001). Since the functioning of an individual is considered as a result of a dynamic interaction between health conditions and contextual factors (Federici, Meloni, & Presti, 2009), then the environment in which people live and conduct their lives can be enhanced by the existence of products and services that meet the individual characteristics. Consequently, since AAL products and services aim at changing the environment in a non-intrusive manner to improve individual performance, they may be considered environmental factors, according to the ICF conceptual framework. ...
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Background: the involvement of the potential end users in the development processes is a relevant issue for the acceptance of Ambient Assisted Living (AAL) products and services. Objective: this study aimed to use the conceptual framework of the International Classification of Functioning, Disability and Health (ICF) to conceptualize instruments for the different phases of the AAL development processes. Methods: personas and scenarios were modified, considering the fundamental concepts of the ICF in order to highlight end user's functioning and health conditions, and an ICF based instrument for usability assessment was defined and validated. Results: the results of several observational studies suggest the adequacy of the ICF based instruments (personas and scenarios and usability assessment instrument). Conclusion: the present study indicates that the ICF based instruments can be useful tools for the development of Ambient Assisted Living products or services.
... 286,290,295,296,300,310,311,313,331,332,335,338,339,348,349,351, 361,367,374,385,395,398,403,408,410,411,423,432,435,436,439,440, 462,466,467,472,480,486,487,490,509,510,522 ,524,525,528,530,546, 560, 572, 573, 577, 579, 583, 586, 588?597, 600, 602, 604?618, 622?625, 627,629,631,632,634,638,639,644,649,650,657,659,660,662,668?670, 672?674, 679, 680, 690?692, 700, 702, 705, 713, 722, 752?799]; 29% (n ? 244) the 12-item version [24][25][26]37,48,52,55,73,79,84,90,92,100, 105,109,111,114,116,117,123,129,134,137,141,142,145,157,162,166, 171,180,185,186,188,191,194,209,212,215,221,224570, 571, 576, 578, 584,586,587,620,621,628,630,635,637,642?644,646,651,653?655,658, 661,664,667,675,678,686,687,689,690,692,694,699,701,703,707,711, 712, 715?720, 723, 724, 727, 731, 732, 734, 800?827]; and 1% (n ? 6) WHODAS-Child.[27,139,[828][829][830][831]Three ...
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Purpose: This systematic review examines research and practical applications of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) as a basis for establishing specific criteria for evaluating relevant international scientific literature. The aims were to establish the extent of international dissemination and use of WHODAS 2.0 and analyze psychometric research on its various translations and adaptations. In particular, we wanted to highlight which psychometric features have been investigated, focusing on the factor structure, reliability, and validity of this instrument. Method: Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology, we conducted a search for publications focused on “whodas” using the ProQuest, PubMed, and Google Scholar electronic databases. Results: We identified 810 studies from 94 countries published between 1999 and 2015. WHODAS 2.0 has been translated into 47 languages and dialects and used in 27 areas of research (40% in psychiatry). Conclusions: The growing number of studies indicates increasing interest in the WHODAS 2.0 for assessing individual functioning and disability in different settings and individual health conditions. The WHODAS 2.0 shows strong correlations with several other measures of activity limitations; probably due to the fact that it shares the same disability latent variable with them. Implications for Rehabilitation WHODAS 2.0 seems to be a valid, reliable self-report instrument for the assessment of disability. The increasing interest in use of the WHODAS 2.0 extends to rehabilitation and life sciences rather than being limited to psychiatry. WHODAS 2.0 is suitable for assessing health status and disability in a variety of settings and populations. A critical issue for rehabilitation is that a single “minimal clinically important .difference” score for the WHODAS 2.0 has not yet been established.
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In this paper we report on the process of translating five mental health outcome measures into Spanish and adapting them to Latino culture. The instruments considered are the World Health Organization-Disability Assessment Scale, the Burden Assessment Scale, the Family Burden Scale, Lehman's Quality of Life Interview and the Continuity of Care in Mental Health Services Interview. A systematic process of translation and adaptation of the instruments was followed with the goal of achieving cultural equivalence between the English and Spanish versions of the instruments in five dimensions: semantic, content, technical, construct, and criterion equivalence. In this paper we present data about the semantic, content, and technical equivalence. Various steps were taken to achieve equivalence in these dimensions, including the use of a bilingual committee, a multi-national bilingual committee, back-translation, and focus groups with mental health patients and their relatives.