**2. WHOQOL-100**

The development of an instrument for evaluation of quality of life purposed by WHO was conducted in 15 centers simultaneously, based in 14 countries. After developing the project WHOQOL, new centers were built. Currently WHOQOL instruments are available in over 50 languages (WHO Field Center for Quality of Life of Bath, 2008).

The development methodology of WHOQOL was sectioned into four major stages: clarifying the concept of quality of life, qualitative pilot study, development of a pilot and finally, field implementation. For the integrated centers, after the completion of the instrument, a protocol was established which consisted in its translation, preparation of the test pilot, development of the response scales and administration of the pilot (The WHOQOL Group, 1998a).

All questions of WHOQOL-100 are closed. It was used a five-point Likert scale, ranging from 1 to 5. These extremes represent 0% and 100%, respectively. There are four different types of response scales, as can be seen in Table 1:


Source: Adapted from The WHOQOL Group (1998b)

Table 1. Response scale of WHOQOL-100

WHOQOL-100 aims at measuring the quality of life globally through six domains: Physical, Psychological, Level of independence, Social relationships, Environment e Spiritual/Religion/Personal beliefs. To obtain the results of WHOQOL instruments applications, the WHOQOL Group recommends the software Statistical Package for the Social Sciences (SPSS).

#### **2.1 WHOQOL-100 scores calculation**

164 Global View of HIV Infection

Notwithstanding the significant diffusion of the WHOQOL, questions concerning the calculation and analysis of the results of those instruments constitute a limitation for its use. In this context, we aimed here at clarifying the mechanism predetermined by the WHOQOL-HIV Group to calculate the WHOQOL-HIV and WHOQOL-HIV-bref instrument

The development of an instrument for evaluation of quality of life purposed by WHO was conducted in 15 centers simultaneously, based in 14 countries. After developing the project WHOQOL, new centers were built. Currently WHOQOL instruments are available in over

The development methodology of WHOQOL was sectioned into four major stages: clarifying the concept of quality of life, qualitative pilot study, development of a pilot and finally, field implementation. For the integrated centers, after the completion of the instrument, a protocol was established which consisted in its translation, preparation of the test pilot, development of

All questions of WHOQOL-100 are closed. It was used a five-point Likert scale, ranging from 1 to 5. These extremes represent 0% and 100%, respectively. There are four different

**SCALE 0% 25% 50% 75% 100%** 

amount

Neither poor nor good

Not at all Slightly Moderately Very Extremely

Very much

nor dissatisfied Satisfied Very

nor unhappy Happy Very happy

An extreme amount

satisfied

Good Very good

scores. Additionally, we proposed an alternative way to perform such calculations.

the response scales and administration of the pilot (The WHOQOL Group, 1998a).

Not at all A little A moderate

dissatisfied Dissatisfied Neither satisfied

unhappy Unhappy Neither happy

CAPACITY Not at all A little Moderately Mostly Completely FREQUENCY Never Seldom Quite often Very often Always

WHOQOL-100 aims at measuring the quality of life globally through six domains: Physical, Psychological, Level of independence, Social relationships, Environment e Spiritual/Religion/Personal beliefs. To obtain the results of WHOQOL instruments applications, the WHOQOL Group recommends the software Statistical Package for the

50 languages (WHO Field Center for Quality of Life of Bath, 2008).

types of response scales, as can be seen in Table 1:

Very

Very

Source: Adapted from The WHOQOL Group (1998b) Table 1. Response scale of WHOQOL-100

Very poor Poor

**2. WHOQOL-100** 

INTENSITY

EVALUATION

Social Sciences (SPSS).

The results of the WHOQOL-100 implementation are expressed through the scores of each facet and domain. The WHOQOL-100 scoring procedure presents the following logic:


The WHOQOL-100 results are expressed in two scales, a variant scale between 4 and 20 points, due to the fact that the facets scores calculation is achieved by multiplying the average of questions that constitute each facet by four. Once each domain is calculated by the simple arithmetic average of facets that composes it. The results are expressed on the same scale of facets. The results are also expressed on a scale from 0 to 100.

#### **2.2 Questions and facets response scale conversion**

The conversion of questions is used in order to standardize all the answers of the instrument, so that the most positive response is 5. Therefore, the most negative response must be 1. Thus, all questions of each facet are converted to the same scale, where the gradual increase in response is equivalent in the same proportion to the increase in the result of the facet.

In cases where all four questions that constitute a facet are arranged in inverted scale, that same logic is used, but only in the domain calculation. That is, the result of these facets is expressed in the original scale: without inversion (the closer to 1, the more positive the result; the closer to 5, the more negative the result). However, when calculating the scores of areas where such facets are found, the score of the latter is converted.

For the conversion of the response scale of questions, the minimum value of the inverted scale question should be replaced by the maximum value of the normal scale question, and the maximum value of the inverted scale question should be replaced by a minimum value of the normal scale question. The same should occur with intermediate values, following this same logic. Thus, the only value that remains unchanged is the central value, which will remain the same in both normal and inverted scales.

It is necessary to be attentive to this fact, because when comparing the results between the facets, the score of a facet with inverted scale cannot be directly compared to the score of a

Quality of Life Assessment in People

Domain I – Physical

Domain II – Psychological

Domain IV – Environment

Source: The WHOQOL Group (1998c)

Table 3. Domains and facets of WHOQOL-bref

Domain III – Social Relationships

Living with HIV/AIDS: Clarifying the WHOQOL-HIV and WHOQOL-HIV-Bref Instruments 167

WHOQOL-100 has a facet that is not included in any domain, the facet Overall Quality of Life and General Health Perceptions (The WHOQOL Group, 1998b). This aspect deals with a self-assessment of quality of life, where the respondents express their point of view

Aiming at providing a tool that demand less time to its filling out, and with satisfactory psychometric characteristics, the WHOQOL Group developed the short version of

The WHOQOL-bref is composed of 26 questions - two questions on self-assessment of quality of life and 24 issues representing each facet of WHOQOL-100. To compound the questions of WHOQOL-bref, it was selected the question of each facet that present the highest correlation with the average score of all facets (The WHOQOL Group, 1998c). After the selection of issues, an analysis was conducted to see if they, factually, represented the corresponding facets. In six facets, the question selected was replaced by another question of the corresponding facet, for, under the bias of experts, there was another question that could best define these six facets (The WHOQOL Group, 1998c). The facets belonging to the domain Level of Independence were incorporated into the Physical domain and the facet belonging to the domain Spiritual / Religion / Personal Beliefs was incorporated into the Psychological domain. Thus, the WHOQOL-bref is composed by four domains: Physical, Psychological, Social

Relationships and Environment, completing the configuration expressed in Table 3:

1. Pain and discomfort 2. Energy e fatigue 3. Sleep and rest 4. Mobility

5. Activities of daily living

11. Bodily image and appearance

13. Spiritual/Religion/Personal Beliefs

7. Work capacity

10. Self-esteem

8. Positive feelings

12. Negative feelings

activities

24. Transport

14. Personal relationships 15. Social support 16. Sexual activity

17. Physical safety and security 18. Home environment 19. Financial resources

6. Dependence on medication or treatments

9. Thinking, learning, memory and concentration

20. Health and social care: accessibility and quality 21. Opportunities for acquiring new information and skills 22. Participation in and opportunities for recreation/ leisure

23. Physical environment (pollution/noise/traffic/climate)

**DOMAINS FACETS** 

concerning their satisfaction with their lives, health and quality of life.

WHOQOL-100, the WHOQOL-bref (The WHOQOL Group, 1996).

**2.4 Short version of WHOQOL-100 (WHOQOL-bref)** 

facet with normal scale. The answers 1, 2, 3, 4 and 5 are to take the values 5, 4, 3, 2 and 1, respectively. The same procedure is used in the conversion of inverted facets, where the scores 4, 8, 12, 16 and 20 are to take the values 20, 16, 12, 8 and 4, respectively.

### **2.3 WHOQOL-100 questions, domains and facets**

Composed by 100 questions, the WHOQOL-100 is sectioned into 24 groups of four questions each, receiving the name of "facets". The group of facets constitutes a "domain". Unlike the composition of facets, the six WHOQOL-100 domains are not constituted by the same number of facets, and may vary from one to eight.

The questions that compose WHOQOL-100 are not arranged in the questionnaire in a logical sequence by domain or facet. They are grouped by type of answer scale. The distribution of WHOQOL-100 facets and areas are listed in Table 2:


Source: The WHOQOL Group (1998a)

Table 2. Domains and facets of WHOQOL-100

WHOQOL-100 has a facet that is not included in any domain, the facet Overall Quality of Life and General Health Perceptions (The WHOQOL Group, 1998b). This aspect deals with a self-assessment of quality of life, where the respondents express their point of view concerning their satisfaction with their lives, health and quality of life.

#### **2.4 Short version of WHOQOL-100 (WHOQOL-bref)**

166 Global View of HIV Infection

facet with normal scale. The answers 1, 2, 3, 4 and 5 are to take the values 5, 4, 3, 2 and 1, respectively. The same procedure is used in the conversion of inverted facets, where the

Composed by 100 questions, the WHOQOL-100 is sectioned into 24 groups of four questions each, receiving the name of "facets". The group of facets constitutes a "domain". Unlike the composition of facets, the six WHOQOL-100 domains are not constituted by the same

The questions that compose WHOQOL-100 are not arranged in the questionnaire in a logical sequence by domain or facet. They are grouped by type of answer scale. The distribution of

> 1. Pain and discomfort 2. Energy e fatigue 3. Sleep and rest

7. Bodily image and appearance

5. Thinking, learning, memory and concentration

11. Dependence on medication or treatments

19. Health and social care: accessibility and quality 20. Opportunities for acquiring new information and

21. Participation in and opportunities for recreation/

(pollution/noise/traffic/climate)

24. Spiritual/Religion/Personal Beliefs

4. Positive feelings

8. Negative feelings

12. Work capacity

14. Social support 15. Sexual activity

skills

23. Transport

10. Activities of daily living

13. Personal relationships

17. Home environment 18. Financial resources

leisure activities 22. Physical environment

16. Physical safety and security

6. Self-esteem

9. Mobility

scores 4, 8, 12, 16 and 20 are to take the values 20, 16, 12, 8 and 4, respectively.

**2.3 WHOQOL-100 questions, domains and facets** 

number of facets, and may vary from one to eight.

WHOQOL-100 facets and areas are listed in Table 2:

**DOMAINS FACETS** 

Domain I – Physical

Domain II – Psychological

Domain III – Level of Independence

Domain IV – Social Relationships

Domain V – Environment

Spiritual/Religion/Personal

Source: The WHOQOL Group (1998a)

Table 2. Domains and facets of WHOQOL-100

Domain VI –

Beliefs

Aiming at providing a tool that demand less time to its filling out, and with satisfactory psychometric characteristics, the WHOQOL Group developed the short version of WHOQOL-100, the WHOQOL-bref (The WHOQOL Group, 1996).

The WHOQOL-bref is composed of 26 questions - two questions on self-assessment of quality of life and 24 issues representing each facet of WHOQOL-100. To compound the questions of WHOQOL-bref, it was selected the question of each facet that present the highest correlation with the average score of all facets (The WHOQOL Group, 1998c).

After the selection of issues, an analysis was conducted to see if they, factually, represented the corresponding facets. In six facets, the question selected was replaced by another question of the corresponding facet, for, under the bias of experts, there was another question that could best define these six facets (The WHOQOL Group, 1998c). The facets belonging to the domain Level of Independence were incorporated into the Physical domain and the facet belonging to the domain Spiritual / Religion / Personal Beliefs was incorporated into the Psychological domain. Thus, the WHOQOL-bref is composed by four domains: Physical, Psychological, Social Relationships and Environment, completing the configuration expressed in Table 3:


Source: The WHOQOL Group (1998c)

Table 3. Domains and facets of WHOQOL-bref

Quality of Life Assessment in People

Symptoms of PLWHA

Social Inclusion

Forgiveness and

Concerns about the

Death and Dying

Source: Adapted from Zimpel & Fleck (2008)

Table 5. Additional questions of WHOQOL-HIV

Blame

Future

**FACETS QUESTIONS** 

Living with HIV/AIDS: Clarifying the WHOQOL-HIV and WHOQOL-HIV-Bref Instruments 169

*related to your HIV infection?* 

*problem?* 

*status?* 

*others?* 

*you when you are dead?* 

*How much do you fear the future?* 

*How much do you worry about death?* 

*destiny bother you?* 

*you would want to?* 

*health condition?* 

*How much are you bothered by any unpleasant physical problems* 

*To what extent do you feel any unpleasant physical problems prevent* 

*To what extent are you bothered by fears of developing any physical* 

To what extent do you feel accepted by the people you know? *How often do you feel you are discriminated against because of your* 

To what extent do you feel accepted by your community?

*To what extent are you bothered by people blaming you for your HIV* 

*To what extent do you feel guilty when you need the help and care of* 

*To what extent are you concerned about your HIV status breaking* 

*To what extent are you concerned about how people will remember* 

*To what extent do any feelings that you are suffering from fate or* 

*How bothered are you by the thought of not being able to die the way* 

*How concerned are you about how and where you will die?* 

*How preoccupied are you about suffering before dying?* 

*How much do you feel alienated from those around you?* 

*How much do you blame yourself for your HIV infection?* 

*How guilty do you feel about being HIV positive?* 

*your family line and your future generations?* 

*To what extent do you fear possible future (physical) pain?* 

*you from doing things that are important to you?* 

The calculation of scores of WHOQOL-bref follows the same logic of WHOQOL-100, except for the calculation of scores of facets. In WHOQOL-bref each facet is represented by a single question, and therefore the scores of facets are not calculated (The WHOQOL Group, 1996).
