WHOQOL-BREF

The World Health Organization Quality of Life (WHOQOL) Group was founded in 1991 to develop a disease-independent and universally applicable health questionnaire. The WHO’s initiative to develop a quality of life assessment arose for a number of reasons.

In the recent past, the focus on the measurement of health has broadened beyond traditional health indicators such as mortality and morbidity, to include measures of the impact of disease and impairment on daily activities and behavior, perceived health measures, and disability/functional status measures. The result of their work in cooperation with 15 international centers was the WHOQOL-100 questionnaire and subsequently, in 1998, its short form, the WHOQOL-BREF. 1,2

Content

The WHOQOL group defines the quality of life as a person’s perception of their position in life, in the context of the culture and value system in which they live, and in relation to their goals, expectations, standards, and concerns. For them, quality of life is thus subject to subjective assessment, embedded in a cultural, social, and environmental context. The WHOQOL-100 and WHOQOL-BREF were developed on this basis.2

The WHOQOL-BREF is a Patient-Reported Outcome (PRO) instrument that can assess the global health status of patients independently of disease across 4 health domains with 24 different domain aspects. Overall, it includes the 26 most important of its predecessor’s 100 questions, representing a considerable and necessary reduction.2 The patient’s recall period covers the past 2 weeks. The WHOQOL-BREF is one of the best-known instruments that has been developed for cross-cultural comparisons of quality of life and is available in more than 40 languages.3 – 6

Score Calculation of the WHOQOL-BREF

Each dimension of the KOOS Score is calculated and evaluated independently and so a total of 5 different scores to evaluate the respective dimensions. The basic requirement for the evaluation of the KOOS is dimension is answered to at least 50%. This includes at least 5 questions under pain, 4 questions under symptoms, 9 questions under activities of daily living (ADL), 3 questions under sports and leisure (SPORT/REC), and 2 questions under quality of life (QoL).

First, one assigns the answer choices their pre-defined point values:

Then the calculation is made using the following formulas:

The possible score ranges in each case from 0 to 100 points. 100 points indicate no restrictions at all due to the affected knee, while 0 points indicate extreme problems/limitations.3

Table 1: WHOQOL-BREF domains

Evaluation of the WHOQOL-BREF

Scoring

First, the patient’s answers are assigned their corresponding predefined scores. These range from 1 to 5 points for all questions. For almost all questions, the worst possible health status corresponds to 1 point, while the best possible corresponds to 5 points. Exceptions to this are questions 3, 4 and 26, where you have to invert the point values:

6-x (x=any score Q3, Q4 or Q26)

Then calculate a domain score for each of the health domains by calculating the average answer points for each domain (sum of answer points divided by number of questions) and multiplying the result by the number 4.

  • Physical health = 4x((6 – Q3) + (6 – Q4) + Q10 + Q15 + Q16 + Q17 + Q18)/7
  • Psychological health = 4x(Q5 + Q6 + Q7 + Q11 + Q19 + (6 – Q26))/6
  • Social relations = 4x(Q20 + Q21 + Q22)/3
  • Environment = 4x(Q8 + Q9 + Q12 + Q13 + Q14 + Q23 + Q24 + Q25)/8

Finally, the 4 domain scores are each converted into a scale from 0 to 100. For this purpose, the number 4 is subtracted from each of the domain scores, and the difference is multiplied by 100/16 or the number 6.25. 0 points represent the worst possible state of health, while 100 points represent the best possible state of health with regard to the respective domain. Thus, the patient’s physical, psychological, social, and environmental state of health are assessed separately.

Converted score = (-domain score-4) x (100/16)

If more than 20% of the questions are missing, the WHOQOL-BREF cannot be evaluated. A maximum of 2 questions per domain may be missing. In such a case, the average of the scores of the remaining questions of the domain is determined and the missing questions are replaced with the average score in each case so that an evaluation can be carried out as above. An exception is the domain “Social Relations”, in which a maximum of 1 question may be missing.6

A syntax for evaluation is provided for SPSS in the user manual of WHOQOL-100 and WHOQOL-BREF.

Strengths

The WHOQOL-BREF is a validated and established questionnaire that, with a length of 26 questions, is an acceptable length for use in clinical trials and patient care. Despite its significant reduction in questions, compared to the WHOQOL-100, it could still show strong validity and good to excellent psychometric properties.2, 8 – 19 Its great relevance is expressed in its use in numerous studies to assess the health status of the respective patients.20

Furthermore, it is a special feature that the WHOQOL-BREF includes an environmental domain that takes a closer look at the patient’s life circumstances, unlike other established PRO instruments such as the SF-36, EQ-5D-5L, or WHODAS 2.0.

Limitations

In a large-scale validation study with over 11,000 patients, it was shown in some centers that there were individual items or questions that did not fit their domain clearly enough. For example, the physical safety item from the environment domain and the energy item from the physical health domain had a stronger correlation to the psychological health domain than to their domain of origin.8

License

The use and evaluation of the WHOQOL-BREF require licensing, although this does not come at a cost. The WHO requires the signing of a user agreement, in which further details about its intended use must be provided.

The signed document can be emailed to WHOQOL@who.int and the desired questionnaire will be sent to you.1 Our PRO consultants happily provide more in-detail information.

Conclusion

All in all, the WHOQOL-BREF is a valid, established, and meaningful PRO instrument for assessing the global health status of patients regardless of their disease. Its implementation is more feasible than in its original form due to its length of 26 questions, but it is not as short as many other short forms of questionnaires, such as the SF-12.

In principle, however, its length is acceptable for research and patient care. Last but not least, the constructional weaknesses in individual items do not impair its overall validity.