WHO Quality of Life Scale

Abstract

The WHO Quality of Life Scale (WHOQOL) is a comprehensive, internationally developed instrument designed by the World Health Organization (WHO) to measure an individual’s subjective perception of their position in life. It considers the context of the culture and value systems in which they live, and relates these perceptions to their personal goals, expectations, standards, and concerns. The version presented here, characterized by numerous items specifically relating to physical symptoms and stigma associated with HIV, is a specialized module (e.g., WHOQOL-HIV) that adapts the core WHOQOL framework to assess the well-being of Persons Living with HIV/AIDS (PLWHA).

The scale is multidimensional, assessing six major domains: Physical Health, Psychological Health, Level of Independence, Social Relationships, Environment, and Spirituality/Religion/Personal Beliefs. The instrument utilizes multiple five-point Likert scales to capture both the frequency/intensity of experiences and the individual’s satisfaction with various life aspects.

Keywords

Quality of Life, QoL, WHOQOL, Psychological Assessment, Health Measurement, Psychometrics, Cross-Cultural, HIV/AIDS, Well-being, Domain Scoring.

Authors

The World Health Organization Quality of Life (WHOQOL) Group.

Purpose

The primary purpose of the WHOQOL scale is to establish a universally applicable and culturally sensitive measure of Quality of Life (QoL) that can be used across diverse populations and cultures. It was developed in response to the need for an instrument that captures subjective well-being beyond traditional clinical indicators of health or disease status.

The scale serves multiple functions, including facilitating cross-cultural comparisons of QoL data in large-scale epidemiological studies, evaluating treatment efficacy in clinical trials, and providing a holistic assessment tool for use in clinical practice. The detailed item list provided highlights its utility in assessing the complex physical, psychological, and social challenges faced by individuals dealing with chronic conditions, such as the specific concerns related to HIV infection.

Construct

The WHOQOL instrument operationalizes the subjective, multidimensional construct of Quality of Life. The scale is structured to measure QoL across six comprehensive domains, reflecting the consensus reached during the international development phase of the project:

• Domain I: Physical Health (e.g., Pain and discomfort, Energy and fatigue, Sleep and rest, Symptoms related to PLWHA).
• Domain II: Psychological Health (e.g., Positive feelings, Thinking, learning, memory and concentration, Self-esteem, Bodily image and appearance, Negative feelings).
• Domain III: Level of Independence (e.g., Mobility, Activities of daily living, Dependence on medication or treatments, Work capacity).
• Domain IV: Social Relationships (e.g., Personal relationships, Social support, Sexual activity, Social Inclusion).
• Domain V: Environment (e.g., Physical safety and security, Home environment, Financial resources, Health and social care, Opportunities for new information/skills, Leisure activities, Physical environment, Transport).
• Domain VI: Spirituality/Religion/Personal Beliefs (SRPB) (e.g., Forgiveness and Blame, Concerns about the Future, Death and Dying).

Validity

The validity of the WHOQOL instrument has been established through extensive field testing in multiple countries. Studies confirm that the scale demonstrates strong criterion validity, particularly through the correlation of domain scores with global measures of QoL and general health perceptions (Items 60, 61, 62, 88).

Construct validity is supported by the instrument’s ability to differentiate between individuals with varying health statuses and clinical diagnoses. Furthermore, the development process ensured strong cross-cultural conceptual equivalence, confirming that the domains and items are meaningful and relevant across diverse cultural contexts, as highlighted in studies validating national versions (e.g., Bonomi et al., 2000).

Reliability

The reliability of the core WHOQOL domains is consistently reported as high across international studies. Internal consistency, measured primarily by Cronbach’s alpha coefficients, generally meets or exceeds the psychometric standard of 0.70 for individual domain scores, indicating that items within each domain measure the same underlying construct effectively.

Test-retest reliability has also been confirmed, demonstrating the stability of scores over short assessment intervals, which is essential for monitoring changes in QoL over time in clinical and longitudinal research settings.

Factor Analysis

Factor analysis played a critical role in structuring the WHOQOL. Initial exploratory factor analysis of the comprehensive item set (WHOQOL-100) led to the robust identification of the six distinct domains. This structure was conceptually driven to ensure cultural comprehensiveness and empirically verified to maximize domain independence.

Subsequent confirmatory factor analyses have consistently supported the factorial validity of the derived domain structure, particularly in the shorter, more widely used version (WHOQOL-BREF). This extensive psychometric investigation ensures that the domain scores accurately represent the intended underlying dimensions of psychological and physical well-being.

Instrument

Test Type: Self-report questionnaire, Multidimensional Quality of Life assessment.

Format: The full version (likely WHOQOL-HIV in this context) contains 120 primary items and 37 importance questions. It uses nine different 5-point Likert scales (A-I) to assess frequency, intensity, capacity, or satisfaction. Questions refer to the individual’s experience over the last two weeks.

Language Available: The WHOQOL framework has been rigorously translated and adapted into over 40 languages globally.

Population Group: General population, clinical populations, and specific patient groups (e.g., Persons Living with HIV/AIDS).

Age Group: Adults (typically 18 years and older).

Population Details: Used internationally for healthy and ill individuals, with specialized modules tailored to specific conditions where QoL assessment is critical.

Test Methodology: Can be self-administered or interviewer-administered, depending on the setting and the respondent’s literacy level.

Keywords

Self-Report, Likert Scale, Domain Scoring, Cross-Cultural Research, Mental Health, Physical Health, Subjective Well-being, Health Outcomes.

Authors

Author ORCID Identifier: N/A (Developed by a collaborative group)

Affiliation Email addresses: N/A (Developed by a collaborative group)

Correspondence Address: World Health Organization (WHO), Geneva, Switzerland

Permissions & Fee and Test Year

Permissions: The instrument is developed and maintained by the World Health Organization. Researchers and clinical users are generally required to seek permission from the WHO for its use, especially for commercial applications. The instrument is intended to be accessible for non-commercial academic research.

Fee: Usage fees vary; often free for non-commercial academic research. Contact the WHO Department of Mental Health and Substance Abuse for specific licensing details.

Test Year: The study protocol for the WHOQOL project was published in 1993. The WHOQOL-BREF (the common 26-item short version) was finalized and published in 1998.

Reference’s

The original PDF documentation for this version (WHO_MSD_MER_Rev.2012.03_eng.pdf) can be downloaded here: http://apps.who.int/iris/bitstream/10665/77776/1/WHO_MSD_MER_Rev.2012.03_eng.pdf?ua=1

Additional resources for the instrument can be found at: http://www.who.int/mental_health/publications/whoqol/en/

Key Academic References:

• WHOQOL Group. (1993). Study protocol for the World Health Organization project to develop a quality of life assessment instrument (WHOQOL). Qual Life Res‚ 2:153–159.
• WHOQOL Group. (1994). The development of the World Health Organization quality of life assessment instrument (the WHOQOL). In: Orley J‚ Kuyken W‚ eds. Quality of life assessment: international perspectives. Berlin: Springer-Verlag‚ 1994:41–57.
• WHOQOL Group. (1998). Development of the World Health Organization WHOQOLBREF quality of life assessment. Psychol Med‚ 28:551–558.
• Skevington‚ S.M.‚ Bradshaw‚ J.‚ Saxena‚ S. (1999). se‎lecting national items for the WHOQOL: conceptual and psychometric considerations. Soc Sci Med‚ 48:473–487.
• Bonomi‚ A.E.‚ Patrick‚ D.L.‚ Bushnell‚ D.M.‚ et al. (2000). Validation of the United States’ version of the World Health Organization Quality of Life (WHOQOL) instrument. J Clin Epidemiol 2000;53:1–12.
• McDowell‚ Ian. (2006). Measuring Health: A Guide to Rating Scales and Questionnaires‚ Third Edition. OXFORD UNIVERSITY PRESS.

Items of the WHO Quality of Life Scale

Questions refer to the last two weeks.

1. Do you worry about your pain or discomfort? (A)

2. How difficult is it for you to handle any pain or discomfort? (B)

3. To what extent do you feel that (physical) pain prevents you from doing what you need to do? (A)

4. How easily do you get tired? (B)

5. How much are you bothered by fatigue? (A)

6. Do you have any difficulties with sleeping? (A)

7. How much do any sleep problems worry you? (A)

8. How much are you bothered by any unpleasant physical problems related to your HIV infection? (A)

9. To what extent do you fear possible future (physical) pain? (A)

10. To what extent are you bothered by fears of developing any physical problem? (A)

11. How much do you experience positive feelings in your life? (A)

12. How much do you enjoy life? (A)

13. How positive do you feel about the future? (B)

14. How well are you able to concentrate? (A)

15. How much do you value yourself? (A)

16. How much confidence do you have in yourself? (A)

17. Do you feel inhibited by your looks? (C)

18. Is there any part of your appearance which makes you feel uncomfortable? (A)

19. How worried do you feel? (B)

20. How much do any feelings of sadness or depression interfere with your everyday functioning? (A)

21. How much do any feelings of depression bother you? (A)

22. To what extent do you have difficulty in performing your routine activities? (A)

23. How much are you bothered by any limitations in performing everyday living activities? (A)

24. How much do you need any medication to function in your daily life? (A)

25. How much do you need any medical treatment to function in your daily life? (A)

26. To what extent does your quality of life depend on the use of medical substances or medical aids? (A)

27. How alone do you feel in your life? (C)

28. How well are your sexual needs fulfilled? (C)

29. Are you bothered by any difficulties in your sex life? (B)

30. How safe do you feel in your daily life? (B)

31. Do you feel you are living in a safe and secure environment? (C)

32. How much do you worry about your safety and security? (A)

33. How comfortable is the place where you live? (A)

34. How much do you like it where you live? (A)

35. Do you have financial difficulties? (A)

36. How much do you worry about money? (A)

37. How easily are you able to get good medical care? (C)

38. How much do you enjoy your free time? (A)

39. How healthy is your physical environment? (B)

40. How concerned are you with the noise in the area you live in? (A)

41. To what extent do you have problems with transport? (A)

42. How much do difficulties with transport restrict your life? (A)

43. Do you have enough energy for everyday life? (D)

44. To what extent do you feel any unpleasant physical problems prevent you from doing things that are important to you? (D)

45. Are you able to accept your bodily appearance? (D)

46. To what extent are you able to carry out your daily activities? (D)

47. How dependent are you on medications? (D)

48. Do you get the kind of support from others that you need? (D)

49. To what extent can you count on your friends when you need them? (D)

50. To what extent do you feel accepted by the people you know? (D)

51. To what extent do you feel accepted by your community? (D)

52. How much do you feel alienated from those around you? (D)

53. To what degree does the quality of your home meet your needs? (D)

54. Have you enough money to meet your needs? (D)

55. How available to you is the information that you need in your day-to-day life? (D)

56. To what extent do you have opportunities for acquiring the information that you feel you need? (D)

57. To what extent do you have the opportunity for leisure activities? (D)

58. How much are you able to relax and enjoy yourself? (D)

59. To what extent do you have adequate means of transport? (D)

60. How satisfied are you with the quality of your life? (E)

61. In general‚ how satisfied are you with your life? (E)

62. How satisfied are you with your health? (E)

63. How satisfied are you with the energy that you have? (E)

64. How satisfied are you with your sleep? (E)

65. How satisfied are you with your ability to learn new information? (E)

66. How satisfied are you with your ability to make decisions? (E)

67. How satisfied are you with yourself? (E)

68. How satisfied are you with your abilities? (E)

69. How satisfied are you with the way your body looks? (E)

70. How satisfied are you with your ability to perform your daily living activities? (E)

71. How satisfied are you with your personal relationships? (E)

72. How satisfied are you with your sex life? (E)

73. How satisfied are you with the support you get from your family? (E)

74. How satisfied are you with the support you get from your friends? (E)

75. How satisfied are you with your ability to provide for or support others? (E)

76. How satisfied are you with your physical safety and security? (E)

77. How satisfied are you with the conditions of your living place? (E)

78. How satisfied are you with your financial situation? (E)

79. How satisfied are you with your access to health services? (E)

80. How satisfied are you with the social care services? (E)

81. How satisfied are you with your opportunities for acquiring new skills? (E)

82. How satisfied are you with your opportunities to learn new information? (E)

83. How satisfied are you with the way you spend your spare time? (E)

84. How satisfied are you with your physical environment (e.g. pollution‚ climate‚ noise‚ attractiveness)? (E)

85. How satisfied are you with the climate of the place where you live? (E)

86. How satisfied are you with your transport? (E)

87. Do you feel happy about your relationship with your family members? (H)

88. How would you rate your quality of life? (F)

89. How would you rate your sex life? (F)

90. How well do you sleep? (F)

91. How would you rate your memory? (F)

92. How would you rate the quality of social services available to you? (F)

93. How often do you suffer (physical) pain? (G)

94. Do you generally feel content? (G)

95. How often do you have negative feelings‚ such as blue mood‚ despair‚ anxiety‚ depression? (G)

96. How often do you feel you are discriminated against because of your health condition? (G)

97. Are you able to work? (D)

98. Do you feel able to carry out your duties? (D)

99. How satisfied are you with your capacity for work? (E)

100. How would you rate your ability to work? (F)

101. How well are you able to get around? (F)

102. How much do any difficulties in mobility bother you? (A)

103. To what extent do any difficulties in movement affect your way of life? (A)

104. How satisfied are you with your ability to move around? (A)

105. Do your personal beliefs give meaning to your life? (A)

106. To what extent do you feel your life to be meaningful? (A)

107. To what extent do your personal beliefs give you the strength to face difficulties? (A)

108. To what extent do your personal beliefs help you to understand difficulties in life? (A)

109. To what extent are you bothered by people blaming you for your HIV status? (A)

110. How guilty do you feel about being HIV positive? (A)

111. To what extent do you feel guilty when you need the help and care of others? (A)

112. To what extent are you concerned about your HIV status breaking your family line and your future generations? (A)

113. To what extent are you concerned about how people will remember you when you are dead? (A)

114. To what extent do any feelings that you are suffering from fate or destiny bother you? (A)

115. How much do you fear the future? (A)

116. How much do you worry about death? (A)

117. How bothered are you by the thought of not being able to die the way you would want to? (A)

118. How concerned are you about how and where you will die? (A)

119. How preoccupied are you about suffering before dying? (A)

120. How much do you blame yourself for your HIV infection? (D)

IMPORTANCE QUESTIONS.

1. How important to you is your overall quality of life? (I)

2. How important to you is your health? (I)

3. How important to you is it to be free of any pain? (I)

4. How important to you is ha‎ving energy? (I)

5. How important to you is restful sleep? (I)

6. How important to you is it to feel free from unpleasant physical symptoms related to your HIV infection? (I)

7. How important to you is it to feel happiness and enjoyment of life? (I)

8. How important to you is it to feel content? (I)

9. How important to you is it to feel hopeful? (I)

10. How important to you is being able to learn and remember important information? (I)

11. How important to you is being able to think through everyday problems and make decisions? (I)

12. How important to you is it to be able to concentrate? (I)

13. How important to you is feeling positive about yourself? (I)

14. How important to you is your body image and appearance? (I)

15. How important to you is it to be free of negative feelings (sadness‚ depression‚ anxiety‚ worry…)? (I)

16. How important to you is it to be able to move around? (I)

17. How important to you is being able to take care of your daily living activities (e.g. washing‚ eating‚ dressing)? (I)

18. How important to you is it to be free of dependence in medications or treatments? (I)

19. How important to you is being able to work? (I)

20. How important to you are relationships with other people? (I)

21. How important to you is it to support others? (I)

22. How important to you is your sexual life? (I)

23. How important to you is it to feel included socially? (I)

24. How important to you is feeling physically safe and secure? (I)

25. How important to you is your home environment? (I)

26. How important to you are your financial resources? (I)

27. How important to you is it being able to get adequate health care? (I)

28. How important to you is it being able to get adequate social help? (I)

29. How important to you are chances for getting new information or knowledge? (I)

30. How important to you are chances to learn new skills? (I)

31. How important to you is relaxation/leisure? (I)

32. How important to you is your environment? (e.g. pollution‚ climate‚ noise‚ attractiveness)? (I)

33. How important to you is adequate transport in your everyday life? (I)

34. How important to you are your personal beliefs? (I)

35. How important is forgiveness to you? (I)

36. How important to you is the future? (I)

37. Are thoughts about death and dying important to you? (I)

Demographic and General Health Questions:

What is your gender? Male / Female

How old are you? (age in years)

What is the highest education you received? None at all / Primary / Secondary / University/Postgraduate

What is your marital status? Single/ Married/ Living as married/ Separated/ Divorced/Widowed

How is your health? (F)

Do you consider yourself currently ill? Yes / No

If something is wrong with your health what do you think it is?___________________________

Answer Scales Used:

• A. (1) Not at all; (2) A little; (3) Moderately (A moderate amount); (4) Very much; (5) An extreme amount
• B. (1) Not at all; (2) Slightly; (3) Moderately; (4) Very; (5) Extremely
• C. (1) Not at all; (2) Slightly; (3) Moderately; (4) Very much; (5) Extremely
• D. (1) Not at all; (2) A little; (3) Moderately; (4) Mostly; (5) Completely
• E. (1) Very dissatisfied; (2) Dissatisfied; (3) Neither satisfied nor dissatisfied; (4) Satisfied; (5) very satisfied
• F. (1) Very poor; (2) Poor; (3) Neither poor nor good; (4) Good; (5) Very good
• G. (1) Never; (2) Seldom; (3) Quite often; (4) Very often; (5) Always
• H. (1) Very unhappy; (2) Unhappy; (3) Neither happy nor unhappy; (4) Happy; (5) Very happy
• I. (1) Not important‚ (2) A little important‚ (3) Moderately important‚ (4) Very important‚ (5) Extremely important