The WHO website on the WHOQOL (includes download of 1996 field trial version): https://www.who.int/toolkits/whoqol

University of Washington; Seattle Quality of Life Group.

• Information on the WHOQOL measures and instructions for receiving permission to use: https://depts.washington.edu/seaqol/WHOQOL-BREF

Neuro Toolkit

• Free online access to the WHOQOL-BREF. Notes areas with noteworthy responses but does not score the assessment: https://neurotoolkit.com/whoqol-bref

WHOQOL-BREF Psychometrics

Note: general population psychometrics are recorded here. Disease/condition specific psychometrics, while important, are far too diverse to list here. Please review the Shirley Ryan Ability Lab resource in “references” as well as any additional disease/condition specific materials relevant to your population.

Reliability

Test-retest reliability

The WHOQOL Group (1998) found Test-retest reliability high for each domain with 0.66 for physical health, 0.72 for psychological, and 0.76 for social relationships, and 0.87 for environment. In this study tests were administered between 2-8 weeks apart, and participants came from four different international sites.

Internal consistency

The WHOQOL Group (1998) found Chronbach’s coefficient alpha (𝛼) values for each domain ranging from 0.66 to 0.84, indicating good internal consistency.

Similarly Goes et al.l (2021) reviewed the psychometric properties of the assessment in Portuguese language among older adults and found Chronbach’s coefficient alpha (𝛼) values for each domain ranging from from 0.64 to 0.90.

Inter-rater reliability

N/A. The WHOQOL-BREF is a self-report measure.

However, Goes et al. (2021) reviewed previously published research on the WHOQOL-BREF and found the measures of internal consistency and correlation coefficients between two studies, one in Portuguese the other in English to be very similar, within .04 to .02 of each other. This indicates the assessment adapts well to linguistic translation and cross-cultural experiences by individuals completing the self-report form.

Intraclass correlations (using ANOVA)

Ilić et al. (2019) found the intraclass correlation for the four domains of the WHOQOL-BREF (Physical health, psychological, Social relationships, and Environment) were between 0.491 and 07769 and significant with p < 0.001.

Validity

Content validity

The WHOQOL-BREF was developed based on the WHOQOL-100. The WHOQOL Group (1998) details the development of the assessment. Notably, in the WHOQOL-100 there are 24 “facets” and in the BREF version the item that had the highest correlation with the total score was chosen for the WHOQOL-BREF (meaning the most statistically relevant and highly correlated item of each facet was included). The final items selected were reviewed by a panel and substitutions were made based on professional opinion and experience. The resulting QHOQOL-BREF has high correlations between domain scores with the WHOQOL-100 ranging from 0.89 to 09.5 (The WHOQOL Group, 1998).

Concurrent validity

The WHOQOL-BREF highly correlates with the WHOQOL-100, the instrument it is based off of. (WHOQOL Group,1998)

Construct validity

Construct validity is established by Skevington & Epton’s (2018) systematic review and meta-analysis of WHOQOL-BREF’s response to change. The researchers found that scores in all domains changed significantly over time, no matter the span of time, sample age, and gender. Skevington & Epton assert that the WHOQOL-BREF detects statistically and clinically relevant changes in quality of life following interventions, treatments, and major life events. (Their findings are of particular note for occupational therapists as the events that impact quality of life, such as satisfaction with ability to perform daily living activities, which corresponds to the role of occupational therapy.)

Relationship to occupational therapy

Each item on the assessment is described here in relation to concepts outlined in the Occupational Therapy Practice Framework: Domain and Process 4th Ed. (AOTA, 2020) hereafter referred to in this table as the OTPF-4.

Items listed here under each domain are reproduced as they are written in the WHOQOL-BREF U.S. Version (WHOQOL Group, 1997).

Overall Quality of Life and General Health

How would you rate your quality of life?

• The OTPF-4 notes that client goals around quality of life are one of the key pieces of information to gather while building an occupational profile. The OTPF-4 also describes OT’s role in establishing (or reestablishing) occupational roles to improve well-being and quality of life (AJOT, 2020). Additionally, ‘quality of life’ is specifically listed as an outcome targeted by occupational therapy.

• Understanding a client’s self-reported quality of life enables OT practitioners to provide the most appropriate and meaningful interventions that are occupation based and enhance the client’s lived experience.

How satisfied are you with your health?

• Satisfaction with health is not specifically addressed in the OTPF-4. However, the role of OT is repeatedly described as to improve satisfaction with occupational performance which the OTPF-4 also linkes to improving overall health and well-being. This idea, that occupation is the means to achieving health and well-being is the core of the profession. Therefore, understanding client satisfaction with their health is of the utmost importance if occupational therapy seeks to improve health through occupation.

Physical Health

To what extent do you feel that physical pain prevents you from doing what you need to do?

• In the OTPF-4 Health Management is included as a category of occupation, and ‘symptom and condition management’ is an occupation in itself. Managing pain is included as an example of symptom/condition management appropriate for OT to address.

• Within the OTPF-4, pain status is understood as a client factor that either supports (in its absence) or hinders occupational performance and engagement, making this item very relevant to occupational therapy.

How much do you need any medical treatment to function in your daily life?

• In the OTPF-4 Health Management is included as a category of occupation, medical treatments are intended to support health.

• Understanding the degree to which medical treatment is required to manage health as well as the client’s perceived need for medical treatment can provide valuable insight. For example, an older adult has a recent diagnosis of insulin dependent type 2 diabetes, but does not monitor blood sugar regularly, could benefit from occupational therapy to support condition/medication management.

Do you have enough energy for everyday life?

• This item addresses energy needed for everyday life which is composed of a myriad of occupations and performance patterns (in the OTPF-4 understood as roles, habits, and routines, rituals). The occupational category of Rest and Sleep is related to this item as it is concerned with addressing activities that enable “restorative rest and sleep to support health, active engagement in other occupations.” (AOTA, 2020, p. 32). The item is indirectly asking about fatigue, which is linked to the occupational performance skill of endurance.

• Energy is linked to occupational engagement and participation in multiple ways and at multiple levels making this a valuable line item for occupational therapists to consider.

How well are you able to get around?

• Functional mobility is an ADL in the OTPF-4 and is required for many occupations.

• OTs assist with “getting around” through assessing mobility and assisting in procurement of mobility aids, environmental modifications, and cognitive aids (such as step by step directions or visual cues).

How satisfied are you with your sleep?

• Rest and Sleep is a category of occupation in the OTPF-4. Understanding client satisfaction with this broad category of occupation can help determine if it is an appropriate area to address as part of a treatment plan. For example, after a medical procedure clients commonly experience difficulty with restful sleep, which can make it even hard to remain focused and attentive throughout the day and impact their overall occupational performance. The occupations associated with rest and sleep can then be incorporated into an occupation based intervention plan using occupation as the means and ends.

How satisfied are you with your ability to perform your daily living activities?

• ADLs are one of the main reasons clients are seen by occupational therapists and are an entire category of occupation.

• If a client indicates a great deal of dissatisfaction with performing ADLs via this item it provides a starting point for further investigation, which can help the therapist target specific areas that are problematic in daily living. For example, a client with low vision may be seeing an OT for home modifications to support mobility related ADLs. This item could easily reveal a need for services in additional areas, such as bathing/showering.

How satisfied are you with your capacity for work?

• Work is a category of occupation in the OTPF-4. Occupations associated with work include paid and volunteer work as well as retirement preparation and adjustment, making this an important item across the lifespan.

• This item asks about satisfaction with capacity for work, depending on how a client answers this item an endless array of performance patterns and skills could be involved however, understanding the subjective experience is equally important. For example, a client may have limited standing endurance, but that skill is needed for a small portion of their job. Therefore the client could rank this item as high in satisfaction with their capacity for work if other performance skills support the majority of tasks associated with the work.

Psychological

How much do you enjoy life?

• While not directly related to OT through the OTPF-4, a low rating on this line item would indicate a need to probe further when building an occupational profile. Follow up questions about occupational history, current engagement/performance, and performance patterns would be appropriate to provide context around the ascribed level of satisfaction. This item would be important to consider if using the WHOQOL-BREF as an outcome measure, it would be noteworthy if a client’s life enjoyment changed after intervention.

To what extent do you feel your life to be meaningful?

• Similarly to the above item, gathering more information on the context of the client’s response is worthwhile and provides potential direction for intervention and goals.

• The OTPF-4 describes occupations as “meaningful engagement in life events” (p. 7) with this understanding it is appropriate to ask, “If my client is reporting their life is not very meaningful, what in their occupational history is leading them to this conclusion? What are they doing or not doing that is contributing to this response?”

How well are you able to concentrate?

• This item can be applied to many occupations and performance patterns and skills and provides personal context. Any action that is not automatic requires some degree of concentration and difficulty with concentration could come about for a myriad of reasons from emotional or psychological to environmental characteristics. Further interview or observation would be needed to understand and interpret this response. However, this item may provide information that is not readily observable as it is about the subjective experience of concentration. For example, individuals in the early stages of dementia frequently notice difficulty concentrating or remembering things before others notice any change.

Are you able to accept your bodily appearance?

• This item is relevant to OT in some situations as it falls into “personal context”. If acceptance of bodily appearance is impacting or impacted by occupational performance this item is relevant. Generally, changing the appearance of one’s body is outside the scope of occupational therapy. However, as stated there are instances where this item is relevant such as under the occupational categories of ADLs and Health Management. In ADLs an inability to perform bathing/shower to or perform personal hygiene and grooming are related to appearance and may impact how one responds to this item, and in this case would be related to and appropriate for OT. Also consider Health Management occupations associated with physical activity, nutrition management, social and emotional health promotion and maintenance, as well as symptom condition management which could also apply. For example, a client recovering from facial burns who is receiving OT services but is reluctant to engage in preferred occupations, such as going out to eat with friends, due to their appearance. How could OT facilitate involvement in this meaningful social occupation?

How satisfied are you with yourself?

• This item in WHOQOL-BREF is related to OT in through the domain of occupational therapy practice when self satisfaction is viewed as a contextual personal factor.

• The OTPF-4 is not only about the process of occupational therapy, but the domain. Within the domain are five key constructs- one of which is “contexts” that can be personal or environmental. The importance of context is emphasized in the OTPF-4 and understood to influence occupational participation and satisfaction with occupational performance.

• This item is valuable while constructing an accurate occupational profile and to tease out additional related contextual factors that impact occupational performance.

How often do you have negative feelings such as blue mood,

despair, anxiety, depression?

• This item is valuable for OTs to consider as it can provide insight into factors that may affect occupational performance. The feelings listed above are commonly associated with difficulties in motivation, initiation, and follow through with occupations. This item potentially relates to the occupational category of Health Management specifically the occupation of symptom and condition management as part of symptom and condition management is, “recognizing symptom changes and fluctuations” (p. 32).

Social relationships

Social Participation is a category of occupation in the OTPF-4, and each of these applies directly to social occupations. This section can provide valuable information on social satisfaction.

How satisfied are you with your personal relationships?

• “Personal relationships” can encompass family participation, peer group participation, friendships, and intimate partner relationships all which are described as social participation occupations in the OTPF-4.

• OT has a large role in supporting meaningful social participation and interactions across the lifespan. Understanding satisfaction with personal relationships contributes to understanding contextual elements of one’s social environment.

How satisfied are you with your sex life?

• “Sex life” can also be understood as intimate partner relationships. The OTPF-4 notes intimate partners may choose to engage in sexual activity or not, that this item in the WHOQOL-BREF is about satisfaction with sex life and not whether or not someone has sex.

• Sex and sexuality can be difficult topics to bring up with clients, this item provides an opportunity to “test the waters” to see if this is an area of occupation that a client wants to address as part of occupational therapy.

How satisfied are you with the support you get from your friends?

• The description of friendship in the OTPF-4 cites providing support as a key element of friendship making this a relevant item for occupational therapists to note.

• Friendship is an important consideration for social occupations. Doing things with people adds meaning to activities, and helps transform activities into occupations. People may not do some things if they lack friends to do them with, or if their friends are unsupportive. It is not uncommon to hear that a client previously engaged in a meaningful occupation but no longer does due to lack of supportive friendships. In this sense, friendship can be both a barrier and support to occupational performance.

Environment

How safe do you feel in your daily life?

• “Safe” is a subjective construct and may be interpreted various ways. Under the heading of environment it is implied that safety in this sense is about environmental factors. The OTPF-4 outlines safety as composed of physical, social, and attitudinal surroundings. Components of one’s environment contribute to subjective feelings of safety. The OTPF-4 provides a detailed list of environmental factor components with examples. If an individual responding to the WHOQOL-BREF indicates they do not feel safe in their environment this is a good indicator for further investigation.

• One of the ways occupational therapy provides interventions that support occupational performance is through environmental modification to support safety in one’s daily life.

How healthy is your physical environment?

• This item fits within the domain of occupational therapy practice as it addresses contextual elements and as such “digging deeper” would likely be necessary to understand what environmental factors influenced the response

• This item is relevant to occupational therapy because if an individual's environment is unhealthy, such as having very poor air quality when the individual experiences frequent asthma attacks, this can impact occupational performance and effectiveness of therapy..

Have you enough money to meet your needs?

• This is not directly described in the OTPF-4, but financial management is an IADL, and Work is a category of occupation. While occupational therapy does not help with finding a job or generating an income, OT is involved in supporting occupations that generate income. This item also serves to provide context about reasonable expectations for what a client can and cannot do in terms of therapy. For example, the importance of no or low cost adaptive equipment for some individuals.

How available to you is the information that you need in your daily-to-day life?

• When accessing information is related to occupational performance this item is relevant. For example, not having readily available information on public bus routes would prevent efficient community mobility and limit the ability to engage in other occupations that require traveling by public transit. In this example access to information falls within the domain of occupational therapy.

To what extent do you have the opportunity for leisure activities?

• Leisure is a category of occupation in the OTPF-4. This item can help identify the level of opportunity for leisure in a client’s life but with further questioning this item can help reveal if opportunity for leisure is appropriate for the client’s occupational balance. For instance, a retired person may interpret this item as having too much opportunity for leisure and not enough structure while a graduate student may interpret this as not enough opportunity for leisure and too much structure with both individuals being dissatisfied with opportunities for leisure.

How satisfied are you with the condition of your living place?

• This item relates to the environmental context of a client’s living space, which when considered through the lens of the OTPF-4 means the natural and built environment as well as objects and furnishings within the environment.

• While applicable to occupational therapy, this question does not reveal whether or not the living space meets the client’s needs or is a safe place for them to live. Consider an older adult who is very satisfied with their multilevel home but is recovering from hip surgery and experiences low vision. For this person, how they answer the question helps the therapist consider how to respond to the situation and how the therapist communicates with the client about their living space.

How satisfied are you with your access to health services?

• Health management is a category of occupation in the OTPF-4. Satisfaction with access to health services is related to health management. This item can provide insight into the experience of accessing health services and an individual's ability to access occupations that support and rely on health management. For instance, an individual with a prosthesis lives a two hour drive from repair and fitting services, if the prosthesis breaks or needs adjustment this person could have limitations in not just health management (getting the prosthetic repaired) but any additional occupations that require use of the prosthesis.

How satisfied are you with your transport?

• Community mobility is an occupation under the category of IADLs. Based on the level of satisfaction with transport an occupational therapist can better understand whether or not this is an area to focus additional attention on to better support occupational performance.