WHO Quality of Life. health other than the cause of a disease or the side effects that come along with it. These other

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1 WHO Quality of Life Overview of the WHO Quality of Life As healthcare progresses globally, so does that evolution of scientific research on healthcare assessments and practices. Healthcare services have started to realize that there are many factors of health other than the cause of a disease or the side effects that come along with it. These other important factors include how the disease affects the completion of daily activities and how it alters a person s behavior (Harper, 1996). Although these factors give more insight as to how a disease affects physical and mental stability, it still does not measure the true quality of life of that person. The time-consuming translation of measures of assessments originating in North America and the UK and also the model of medicine that is progressing today; which focuses highly on just doing the means required to diminish symptoms or totally get rid of the disease, also show the need for a holistic and person-first approach to healthcare treatment. The World Health Organization recognized this need and developed the WHO Quality of Life assessment (WHOQOL). This assessment focuses solely on the person s quality of life and helps bring back a humanistic element to healthcare (Harper, 1996). The WHOQOL was dependent on three crucial stages in order for it to be developed properly and effectively. Stage one included defining what quality of life actually was and how it was important to a person s treatment. Quality of Life is defined as individuals perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns (Harper, 1996). This definition of quality of life is focused less on the person s disability and more on how the person s views their ability to function both physically and mentally and how it affects their daily lives (Harper, 1996). In the second stage of development, information was gathered to figure out what areas and dimensions were most important and should be included in the WHOQOL assessment. Participants,

2 including patients, people without documented disabilities and health professionals coming from 15 worldwide culturally diverse areas engaged in several focus groups in order to come up with these factors (Harper, 1996). 236 QOL questions that covered 29 different areas of concern were gathered for the final assessment. This pilot assessment was then administered to 300 people from each of the 15 areas, completing stage three of development (Harper, 1996). After receiving feed back from the pilot test participants, 100 questions were chosen to be included in the WHOQOL assessment. Each of the 24 dimensions relating to quality of life had four corresponding questions and there were also four questions that related to overall perception of quality of life (Harper, 1996). Recent studies have narrowed down the WHOQOL-100 assessment and created an assessment called the WHOQOL-BREF. The WHOQOL-BREF provides both healthcare providers and participants with a shorter and more practical version of the WHOQOL while still being relevant to assessing quality of life. This assessment is composed of 26 questions, one question coming from 24 different dimensions with two questions focused on the overall quality of life. Both of these assessments can be used by any health professional by signing a user agreement and sending it to the World Health Organization (Harper, 1996). WHO QOL Domains The WHOQOL-BREF assessment is composed of questions that relate to four different domains. These domains include physical health, psychological, social relationships, and environment. In the physical health domain, participants would assess factors including how dependent they are in activities of daily living, if they rely on any medications or aids to get through their daily lives, how often they have energy or fatigue, what their range of mobility and work capacity is, how much pain or discomfort they feel throughout their daily lives, and also how much sleep or rest they get in their daily lives. Physical health is a vital part of quality of life because

3 clients who have physical disabilities or are not physically active may be more susceptible to a lower quality of life due to the limitations they experience because of the physical factors they lack (Harper, 1996). In the psychological health domain, participants would assess factors including how they feel about their bodily image or their appearance, how often they experience negative or positive feelings and in what areas, how much self-esteem they encompass, what their spirituality, religion, and personal beliefs consist of, and how their thinking, learning, memory and concentration is affected. Psychological health is a vital component of quality of life because a client that does not have a healthy brain or the capacity to think and do in certain situations, may view the world a lot differently a require a lot of assistance in controlling their thoughts (Harper, 1996). In the social relationship health domain, participants will assess factors including their personal relationships, realm of social support, and how sexually active they are. Social relationships are an important factor in quality of life because it is a natural instinct of humans to want to be accepted and loved; if these feelings are not present it could alter a person s perception of their life tremendously (Harper, 1996). Lastly, in the environmental health domain, participants will assess factors including their access to financial resources, how they feel about their freedom, physical safety and security; the accessibility and quality of their health and social care, their home environment, what opportunities they have for acquiring new information and skills, how involved they are in recreation and leisure activities, the realms of their physical environment, and their ability/access to transportation. Environmental factors are also an important factor in quality of life because people truly feed off of the vibes they get from their environment. It is important to encompass yourself with good vibes to ensure the highest quality of life (Harper, 1996). Reliability and Validity

4 In order to make an assessment standardized to use out in the field, it must first go through a series of research tests to make sure that it is proven to be reliable and valid. The reliability of the assessment describes how consistent and stable it is, while the validity describes how accurate it is. The assessment must first be able to show consistent results across the board when used on a variety of people while also proving that it is measuring exactly what is was intended for (Logan, 2016). In a recent study conducted on medical students in New Zealand, the WHOQOL-BREF assessment was tested to ensure just how valid and reliable it really was. 274 students were assessed, 124 being male, and were either of European, Asian, Maori, or Pasifika ethnicity, with 47 participants indicating they were of a different ethnicity that was not listed. After the completion of the assessment, researchers used Cronbach s alpha to assess reliability. In order to be deemed as reliable, the alpha score had to reach at.70 or above. The WHOQOL-BREF reached an overall alpha score of.89, with each separate domain alpha score falling between.74 and.77. The validity of the WHOQOL-BREF was found by linking each individual question and domain score with the two questions that were independent of a domain (Item 1 & 2), asking about quality of life and health as a whole (Krageloh et al., 2011). They found that all 24 remaining items were significantly correlated with Items 1 and 2 (p<0.01), except for Item 4, which was significantly correlated with Item 2, but not with Item 1 (Krageloh et al., 2011) They also found that every domain was directly linked to Item 1 and 2 as well. Overall researchers found that the WHOQOL-BREF was proven to be both a reliable and valid assessment. The validity of the assessment was very good with the exception of a minor correlation and reliability was excellent showing scores of well over the required alpha of.70, proving great internal consistancy (Krageloh et al., 2011). Administration Features When administering the WHOQOL-BREF to new testing centers, strict procedures must be followed in order to ensure the highest competency. Feedback from 300 participants is required, just like that of the WHOQOL-100, and these participants must the categorized as an adult within their

5 culture. 50% of the pilot participants should be <45 years old and the remaining 50% should be 45 years or older. 50% of the participants should be male and 50% should be female, and also 250 of the participants should have a documented disease or impairment with the remaining 50 having no documented health issues (Harper, 1996). The participants with health issues should be varied in severity ranging from some patients having extremely severe conditions to patients who may have conditions that would not necessarily alter their quality of life. The assessment should be selfadministered unless the participant requires any interviewer assistance or administration. In this case the interviewer must read out the assessment to the participant to ensure the highest competency of the participant (Harper, 1996). In the healthcare field, the WHOQOL assessments will be administered to develop a baseline score for patients entering treatment and also as an intermediate assessment to detect improvement over the course of treatment. It may be used in a wide array of settings ranging from epidemiological research to clinical practice. For professionals involved in epidemiological research, the WHOQOL assessments will provide results centered toward different populations quality of life and allow them to be compared to others (Harper, 1996). For professionals in the clinical setting, the WHOQOL assessment could be a great tool that allows healthcare providers to obtain a baseline about their patients. From this, the provider can focus on which areas their client needs the most treatment and would be a great aid in making treatment decisions. Later, the professional can administer the test again to identify any changes or improvements their client has made in their quality of life over the time that the treatment was being administered. The WHOQOL-BREF is also a quick and easy assessment to administer allowing faster feedback scores and a quicker start to treatment (Harper, 1996). Scoring the WHO QOL The WHOQOL-BREF assessment is graded based on the scores derived from the answers pertaining to each of the four domains, and also the two separate questions pertaining to overall

6 quality of life and perception of health. A higher overall score represents feelings of a greater quality of life while lower scores represent feelings of a low quality of life (Harper, 1996). Each question can be answered using a score of 1-5, 1 meaning not at all, very poor/dissatisfied, or never, depending on the question; and 5 meaning extremely, very good/satisfied, completely, or always, depending on the question. Each separate score for each domain represents the person s conception of his or her own quality of life pertaining to that domain. To calculate the score for domain 1 (physical health), the score for questions 3 & 4 must be subtracted by 6 and then added together with questions 10, 15, 16, 17, and 18 to obtain a raw score. To calculate domain 2 (psychological), the score for question 26 must be subtracted by 6 and then added to questions 5, 6, 7, 11, and 19. To calculate the raw score for domain 3 (social relationships), the score for questions 20, 21, and 22 must be added together. Lastly, to calculate domain 4 (environment), the score for questions 8, 9, 12, 13, 14, 23, 24, and 25, must be added together. After obtaining a raw score for each domain, a table must be followed that will show how to convert a raw score to a standard score. After converting your raw score to your standard score, all domain scores must be added together and divided by 4 to obtain an overall quality of life score (Harper, 1996). If there is 20% or more of the test questions not answered, a score cannot be obtained. There should be no more than two questions unanswered from each domain, excluding domain three where there can only be one question unanswered, or a score for that domain cannot be calculated (Harper, 1996). Appropriateness to RT Practice As Recreational Therapists, it is our job to focus our treatments around the person as a whole. This includes taking into prospect their physical health, psychological health, social relationships, and environment; aka the four domains of the WHOQOL-BREF. Any adult in any facility would be able to complete the WHOQOL as long as they were able to fully process what each question was asking them. First and foremost, the WHOQOL-BREF is a great tool to use to create a baseline of

7 information on the specific client. Recreational Therapists can take the information collected from the assessment and use it as a guideline to start their treatment process. For example, if a mental health client produces a low score in physical health, but produces high scores in the other three domains, the RT would then know that involving their client in interventions geared toward improving physical health would be most beneficial. The WHOQOL-BREF is also a good tool to use again later to assess if the client s quality of life has improved over the course of treatment. For example, if a client scored low on the social relationships aspect of the assessment and was involved in various social groups during their treatment, the RT could then administer the WHOQOL-BREF assessment again to see if the client s social relationship score showed any improvement. Lastly, the WHOQOL-BREF assessment can also be used as a feedback tool to assess if interventions are working with clients. For example, if a client that is involved in groups that are focused on the beginning results of their assessment, takes the assessment again later in treatment and shows no improvement in scores, the RT would then be able to take in to account that the groups used in their treatment may need to be improved in certain aspects to become more beneficial. Personal Assessment Results and Reflection My overall score for the WHOQOL-BREF assessment was a 16. I scored a 15 in domains 1 (physical health) and 2 (psychological), and I scored a 17 in domains 3 (social relationships) and 4 (environment). I feel like this score is a little lower than I would like, but is an accurate representation of my quality of life now. My physical health now is not where it used to be, which could be the cause for some of the reasons I do not get an adequate amount of sleep some nights and also why I feel a lower amount of energy and a higher amount of fatigue than I have in the past. I believe that my physical health score directly correlates to my psychological score because lack of desired amount of physical health affects the way I feel about myself and controls my self-esteem. Although I generally have a good self-esteem I do believe that if I could increase my physical health it would

8 cause my psychological health to increase as well. I think that my scores for these two sections are also affected by my schooling. Schooling causes me a lot of stress because the determination to make good grades and make a future for myself weighs heavily on me, which could in turn lower my psychological health score. I also believe that amount of time I spend doing school work or thinking about school takes away from time that I could be exercising or catching up on sleep which goes back to affecting my physical health score. I am satisfied with my scores for domain 3 and 4, because my socials relationships and the environment I am in at Western has a good effect on me. I am happy with the friends I have here at school and also the relationship I have with my boyfriend. I feel that my relationships are healthy and I have good people in my life that help make me an overall happy person. I am also encompassed in a good environment here at Western. I have access to the things I need while in and out of class and there are a lot of opportunities for me to participate in extracurricular activities. I am involved in the Recreational Therapy club and also in my sorority, which also helps with creating a good environment. Thanks to the help of my parents, I do not have any financial problems and I have easy access to healthcare facilities that are offered on campus if I was to need them. Taking this assessment made me realize just how important and beneficial it really is. Because I answered each question truthfully and to the best of my ability, I was provided with an accurate representation of my quality of life score. I now know which domains of my health I need to focus on more in order to increase my quality of life and also which domains of my health are considered to be at a good level. When using this assessment in the field, I will make sure that my clients know how important it is to think about each question and answer it truthfully. The more accurate a client s assessment score is, the better I will be able to individualize interventions making it more beneficial for their treatment. Having taken this assessment will also help me to relate more with my clients needs. I saw exactly what places I needed improvement in, which can help me to help others see where their own improvements are needed. I will also be able to help clients see where their strengths

9 are and identify what strategies they use in order to keep their quality of life high in that particular domain. Overall, I believe that the WHOQOL is a very helpful and highly needed assessment for Recreational Therapy because it not only provides professionals with a baseline about the clients; it also helps to individualize treatment and improve treatment services for the future. WHO Quality of Life-BREF The following questions ask how you feel about your quality of life, health, or other areas of your life. I will read out each question to you, along with the response options. Please choose the answer that appears most appropriate. If you are unsure about which response to give to a question, the first response you think of is often the best one. Keep in mind your standards, hopes, pleasures and concerns. Think about your life in the last four weeks. Name Emilee Date Administered poor Poor Neither poor nor good Good good 1. How would you rate your quality of life? poor Poor Neither poor nor good 2. How satisfied are you with your health? The following questions ask about how much you have experienced certain things in the last four weeks. Not at all A little A moderate amount much Extremely 3. To what extent do you feel that physical pain prevents you from doing what you need to do? 4. How much do you need any medical treatment to function in your daily life? 5. How much do you enjoy life? 6. To what extent do you feel your life to be meaningful? 7. How well are you able to concentrate? 8. How safe do you feel in your daily life? 9. How healthy is your physical environment? The following questions ask about how completely you experience or were able to do certain things in the last four weeks. Not at A all little Moderately Mostly Completely 10. Do you have enough energy for everyday life? 11. Are you able to accept your bodily appearance? 12. Have you enough money to meet your needs? 13. How available to you is the information that you need in your day-to-day life? 14. To what extent do you have the opportunity for leisure activities? Good good

10 Neither poor Poor Good poor nor good good 15. How well are you able to get around? dissatisfied Dissatisfied Neither satisfied or dissatisfied Satisfied satisfied 16. How satisfied are you with you sleep? 17. How satisfied are you with your ability to perform your daily living activities? dissatisfied Dissatisfied Neither satisfied or dissatisfied Satisfied satisfied 18. How satisfied are you with your capacity for work? 19. How satisfied are you with yourself? 20. How satisfied are you with your personal relationships? 21. How satisfied are you with your sex life? 22. How satisfied are you with the support you get from your friends? 23. How satisfied are you with the conditions of your living place? 24. How satisfied are you with your access to health services? 25 How satisfied are you with your transport? The following question refers to how often you have felt or experienced certain things in the last four weeks. Never Seldom Quite often often Always 26. How often do you have negative feelings such as blue mood, despair, anxiety, depression? Do you have any comments about the assessment? SCORING: Equations for computing domain scores Raw Score Standard Score Domain 1 Physical Health (6-Q3) + (6-Q4) + Q10 + Q15 + Q16 + Q17 + Q Domain 2 Psychological Q5 + Q6 + Q7 + Q11 + Q19 + (6-Q26) Domain 3 Social Q20 + Q21 + Q22 Relationships + + Domain 4 Environment Q8 + Q9 + Q12 + Q13 + Q14 + Q23 + Q24 + Q Total Domain Scores 64 Quality of Life Score (divide the Standard Total Domain Scores by 4) 16

11 References Harper, A. (1996). WHOQOL-BREF introduction, administration, scoring, and generic version of the assessment. Retrieved from Krageloh, C.G., Henning, M.A., Hawken, S.J., Zhao, Y., Sheperd, D., & Billington, R. (2011). Validation of the WHOQOL-BREF quality of life questionnaire for use with medical students. Education for health. Auckland, New Zealand. Retrieved from _1/courses/FALL2016.RTH401-01/Validation%20of%20the%20WHOQOL_BREF_2011.pdf Logan, Debbie (2016, September 12). Lecture 2 RTH 401: Psychometrics and Measurement Principles. Powerpoint lecture presented in HHS room 133 on the Western Carolina University campus.