WHOQOL-OLD

Manual of the questionnaire on

the quality of life in the elderly.

WORLD HEALTH
ORGANIZATION
This manual was written by Professor Mick Power and Dr. Silke Schmidt on behalf of the WHOQOL-OLD
group, and its translation and adaptation into Portuguese was authorized by the authors. The Portuguese
 MANUAL DEL CUESTIONARIO WHOQOL-OLD

adaptation was done under the supervision of Dr. Eduardo Chachamovich and Dr. Marcelo Pío de Almeida
Fleck.The study was funded under the Fifth European Commission, QLRT-2000-00320 and developed under the
auspices of the World Health Organization Quality of Life Group (WHOQOL Group).The Brazilian center
obtained funding from FIPEHCPA (Research Incentive Fund of the Hospital de Clínicas de Porto Alegre). The
WHOQOL group consists of a coordinating group and collaborating researchers from the following centers:
Professor M. Power, K. Quinn, K. Laidlaw, H. Toner, of the University of Edinburgh, UK; Dr. R. Lucas, Catalan
Institute of Aging, Barcelona, Spain; Professor S. Skevington, Dr F. McCrate, University of Bath, U.K.; Dr. M.
Amir *, Y. Ben Ya'acov, Tal Narkiss-Guez, Department of Behavioral Sciences, Ben-Gurion University of the
Negev, Israel; Professor L. Kullman, National Institute for Medical Rehabilitation, Hungary; G. Bech-Anderson,
Dr. K. Martigny, Psychiatric Research Unit, Copenhagen, Denmark; Prof. Ji Qian Fang, Dr Yuantao Hao, Sun
Yat-sen University of Medical Sciences, Guangzhou, China; Prof. M.C. Angermeyer, Dr H. Matschinger, I.
Winkler, Department of Psychiatry, University of Leipzig, Germany; Professor A/ G. Hawthorne, Australian
Centre for Posttraumatic Health, University of Melbourne, Australia; Dr. M. Kalfoss, Faculty of Nursing,
University of Menighetssosterhjemmets, Oslo, Norway; Dr A. Leplege, INSERM, Paris, France; Dr E.
Dragomirecka, Prague Psychiatric Center, Prague, Czech Republic; Dr. M. Martin, Mr. D. Bushnell, Associates
for Health Services Research, Seattle, U.S.A.; Dr. M. Tazaki, Department of Science, Tokyo University of
Science, Tokyo, Japan; Professor M. Eiseman, Department of Psychology, University of Tromsoe, Norway; B.
Nygren, Department of Nursing, Umea University, Sweden; Dr a. Molzahn, Faculty of Human and Social
Development, University of Victoria, Canada; Dr J. Ceremnych, Scientific Department of Gerontology
Problems, Institute of Clinical and Experimental Medicine, Vilnius, Lithuania; Dr. M. Mancha, Department of
Psychiatry and Forensic Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil; Professor K.
F. Leung, Hong Kong Hospital Authority, Kowloon, Hong Kong, Professor N. von Steinbüchel, Center for
Neurogerontopsychology, Clinic of Psychiatric Geriatrics, Hospital of the University of Geneva, Switzerland;
Associate Professor E. Eiser, Celal Bayar University, Manisa, Turkey; Professor l. Schwartzmann, Department
of Medical Psychology, Uruguay; Dr R. Killian, Department of Psychiatry, University of Ulm, Germany; Dr. S.
Schmidt, Holger Muehlan, University of Hamburg, Germany.

*We mourn the passing of Dr. Marianne Amir in January 2004.

Information on the Brazilian version of the WHOQOL-OLD instrument can be obtained through:
Dr. Eduardo Chachamovich
echacha@Terra.com.br

Prof. Dr. Marcelo Pío de Almeida Fleck

mfleck.voy@Terra.com.br

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General information about the WHOQOL-OLD project can be obtained from:

Professor Mick Power
mjpower@staffmail.ed.AC.uk

Introduction
The main objective of developing the OLD questionnaire was to answer two basic questions about the use of
WHOQOL instruments in older adults: Do standard instruments (WHOQOL-100 and WHOQOL-BREF)
perform well, within a range of criteria, in an older adult population?And second, do additional items need to be
added to the standard adult instruments in order to assess quality of life adequately in the older adult population?

This study also aims to find out whether it is possible to have a single cross-cultural questionnaire for all older
adults, or whether each culture requires a specific questionnaire.While it was possible to generate a common
version of the WHOQOL instrument for use with young people, which has been supported by empirical analysis
(WHOQOL Group 1998-, 1998-b), there is the possibility that different cultural attitudes towards older adults
may require the development of different questionnaires, a possibility that was carefully examined in different
centers.Feedback from the focus groups and data analysis also allowed us to question how well the existing

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WHOQOL-100 survey variables selected for use with younger people performed when used with older adults.
Thus, one of the objectives of the present study was to test whether the existing items of the WHOQOL-100
needed to be changed in one way or another or supplemented with an additional questionnaire.

In summary, the overall objective of the WHOQOL-OLD group was to adapt the WHOQOL for use with older
adults and then to test its use in a series of cross-cultural field studies. Such adaptation consisted of the
development of a complementary questionnaire that can be added to the existing WHOQOL instruments. The
ultimate goal of this work was the construction of a WHOQOL questionnaire for older adults (WHOQOL-OLD).

The WHOQOL-OLD project

The WHOQOL-OLD project aims to develop and test the assessment of quality of life in older adults and started
in 1999 as a scientific cooperation of different centers.The aim of the project was to develop and test a standard
measure of quality of life in older adults for international/intercultural use. The project was funded under the
Fifth European Commission, QLRT-2000-00320 and was held under the auspices of the WHO Quality of Life
Group (WHOQOL Group).The development of the questionnaire was carried out according to the following
multi-stage procedure: (a) initial development of relevant quality of life questions (variables) and their
translation: focus group work within the collaborating centers and the iterative process of the Delphi method
among the collaborating centers for the generation of variables; (b) pilot testing of the questionnaire with
appropriate modification (refinement, reduction of items); (c) field studies of the questionnaire; (d) final
analysis: statistical analysis, project report and publication of the manual.

WHOQOL-OLD Questionnaire Development

Overview

The WHOQOL-OLD coordinating group center developed a draft protocol based on previous WHOQOL group
experience in conducting international collaborative research for the development of the WHOQOL-100 and
WHOQOL-BREF (WHOQOL Group 1998-, 1998-b). After development of the initial protocol, it was circulated
to each center for comment.It was revised iteratively through the Delphi method until there was unanimity
among the participating centers.In summary, the steps for the development of the WHOQOL-OLD followed the
methodology published in the WHOQOL questionnaire, which consisted of focus group work in the
collaborating centers, generation of variables, pilot testing, corrections, reduction of variables and finally the
field study of the instrument, as described below.Prior to the focus group work, the repeated Delphi process was
also used to identify gaps in the coverage of the WHOQOL-100 instrument that might be of interest to older
adults, or any other questions about the use of the WHOQOL with older adults.The proposed WHOQOL
questionnaire went through several stages of instrument development in a simultaneous cross-cultural approach
(see Power, Quinn, Schmidt and the WHOQOL group, 2005).After determining the focus groups and developing

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a set of international items, from which only items related to the elderly were selected, while the standard items
were processed separately. Additional phases would include a translation process following international
guidelines (Guillemin et al., 1993) as well as pilot testing of the instrument (Bullinger et al., 2002). The field
study analysis of the WHOQOL-OLD questionnaire included psychometric evaluations of both individual items
and the structure of the questionnaire. These analyses led to the final version of the WHOQOL-OLD
questionnaire, reported in detail in other texts (Power, Quinn, Schmidt & WHOQOL Group, 2005).

Table 1 Centers included in the development of the WHOQOL-OLD questionnaire

Center Country Pilot test (n) Field study (n)
Edinburgh Scotland 303 116
Bath England 331 145
Leipzig Germany 433 354
Barcelona Spain 302 271
Copenhagen Denmark 467 384
Paris France 130 164
Prague Rep. Czech 350 325
Budapest Hungary 304 333
Oslo Norway 372 324
Victoria Canada 430 202
Melbourne Australia 364 376
Seattle USA 235 295
Beer-Sheva Israel 312 250
Tokyo Japan 410 188
Umea Sweden 315 455
Guangzhou China 478 -
Hong Kong China 319 -
Porto Alegre Brazil 339 328
Montevideo Uruguay 256 248
Izmir Turkey 345 327
Geneva Switzerland 161 139
Vilnius Lithuania 445 342
WHOQOL-OLD GROUP Global 7401 5566

Initial development
The protocol for focus group selection established a common framework for interpreting and evaluating the data
reported by each center.Once accepted, the protocol was used at each center as a guide for planning and
conducting focus groups; with the goal of showing concerns such as the quality of life of older adults, and for
reporting each center's data to the Edinburgh Coordinating Center.The focus group discussions included four
parts: (a) General unstructured discussion on aspects of quality of life that were important to older adults; (b)
Comments on the phases and variables of the WHOQOL-100 instrument and their assessment; (c) Feedback on
additional phases and variables that had been suggested by the centers during the application(c) Feedback on
additional phases and variables that were suggested by the centers during the Delphi method described above;

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and (d) Collection of participants' suggestions for additional areas of quality of life or items that participants
indicated were not addressed during the discussion.

Each center conducted four focus groups with older adults (with approximately equal numbers of those aged 60
to 80 and over 80; equal numbers of men and women; and equal numbers of healthy as well as ill participants)
one group with their caregivers and one group with health professionals who worked with older adults (i.e., at
least six focus groups).

This process resulted in the generation of a set of 40 pilot items, which were conceptually grouped by the
participating centers into six items.In addition, the work with the focus groups suggested four items
complementary to the WHOQOL-100 stages: two items for "Sexual Activity", one variable for "Thinking" and
one for "Home".

Pilot test

Population

The pilot test was conducted in 22 WHOQOL centers around the world (Table 2).Each center was asked to
conduct a test with a sample of at least 300 older adults, respecting the following sampling scheme:
approximately equal numbers of men and women in the range of 60 to 80 years and over 80, and equal numbers
of healthy and diseased persons (the only exceptions being the Geneva and Paris centers, which would share a
recruitment of French-speakers with each other).The data presented in Table 2 provide summary descriptions of
the samples from each of the 22 centers in terms of sample size, age, gender and health status.

Table 2 - Overview (Sample size, selected sociodemographic characteristics) of the WHOQOL-OLD pilot study
sample from each participating center.
Center Sample size Age Gender (women) Health status
("Healthy")*.
N M ± DP % %
Edinburgh (Scotland) 303 73.3±8.2 68.5 83.8
Bath (England) 331 74.3±8.0 59.5 84.5
Leipzig (Germany) 433 72.3±8.2 43.6 65.6
Barcelona (Spain) 302 74.5±7.5 56.6 63.6
Copenhagen (Denmark) 467 71.3±8.3 52.5 83.6
Paris (France) 130 73.3±8.2 55.9 93.0
Prague (Rep. Czech 350 74.1±8.2 50.3 62.0
Republic)
Budapest (Hungary) 304 74.7±8.1 65.1 41.1
Oslo (Norway) 372 73.5±6.6 74.6 73.2
Victoria (Canada) 430 74.4±8.6 73.0 89.3
Melbourne (Australia) 364 74.9±7.9 55.1 82.0
Seattle (USA) 235 72.8±7.6 63.4 57.9
Beer-Sheva (Israel) 312 73.0±8.3 52.4 71.3

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Tokyo (Japan) 410 70.8±8.0 55.7 78.6

Umea (Sweden) 315 73.3±6.6 54.6 74.2
Guangzhou (China) 478 73.6±8.5 48.5 61.5
Hong Kong (China) 319 72.5±6.9 63.7 64.4
Porto Alegre (Brazil) 339 73.4±8.3 56.0 57.5
Montevideo (Uruguay) 256 71.6±7.4 61.3 72.3
Izmir (Turkey) 345 70.3±5.8 52.2 57.4
Geneva (Switzerland) 161 74.7±8.3 75.8 90.6
Vilnius (Lithuania) 445 73.3±9.4 52.4 54.8
Total 7401 73.1±8.0 57.8 70.1
Note: * "Healthy" or "Unhealthy" as subjectively defined.

This sample is so far the largest sample of older adults to whom the WHOQOL-100 has been administered. The
"Health Status" category in Table 2 refers to the subjective assessment of health, independent of objective health
conditions; therefore, 70.1% of the sample describe themselves as healthy.It is interesting to note that 92% of
people with one or more comorbidity conditions still assess themselves as healthy despite the presence of
"objective" co-morbid conditions. As expected, the statistics indicate that there are some differences between the
centers in terms of these descriptive variables.

Measures

The purpose of the pilot test was to obtain data for the items of the WHOQOL-OLD instrument by testing and
reducing them.The instruments included in the pilot study were, therefore, the WHOQOL-100 (WHOQOL
Group 1998-a), being an established measure of quality of life with proven reliability and validity; a set of 40
items in the WHOQOL-OLD pilot questionnaire generated from the work of the focus groups;a set of core
questions asking about the importance of each WHOQOL-100 and WHOQOL-OLD item to respondents
(WHOQOL Group 1998-a); and a series of sociodemographic and health-related questions about co-morbid
conditions.

Methods

The basic method of statistical analysis was to combine the qualities of "classical" and modern (probabilistic)
psychometric approaches to scale development.Following previous WHOQOL analytical guidelines (WHOQOL
Group 1998-b), the analysis examined item response frequency distributions, missing values (missings) analysis,
item correlations, item scores, and reliability analysis.In particular, the use of the Multitrait Analysis Program
(MAP; Hays et al., On the other hand, the item response theory (IRT) approach using Rasch's unidimensional
measurement model (Andrich 1988), as implemented in the RUUM program (Andrich 2001) and in the
WINMIRA program (von Davier, 2001).An iterative approach was used in which the initial larger set of items
was reduced through a combination of classical and IRT approaches; thus, previous work in focus groups and

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with the Delphi method, of which the Delphi method was used, was used.Thus, previous work in focus groups
and with the Delphi method, from which the WHOQOL-OLD items had been obtained, also provided an initial
item structure for the scale items, providing the starting point for the subsequent structural analysis of the model.

Field study

The field study allowed participating centers to conduct everything from epidemiological studies to validity
analyses and evaluation of longitudinal studies. Each center, however, included a basic data set that could be
further analyzed to produce the final version of the WHOQOL-OLD questionnaire.

Population

Field study analyses were conducted on a sample of 5566 with data from 20 national centers (Guangzhou and
Hong Kong were not included). The sample size recruited from each center ranged from 116 (Edinburgh) to 455
(Umea; see Table 3).

Table 3 - Overview (Sample size, selected sociodemographic characteristics) of the WHOQOL-OLD field study
sample from each participating center (n=5566).
Center Sample size Age Gender (women) Health status
("Healthy")*.
N M ± DP % %
Edinburgh (Scotland) 116 77.59±10.47 67.2 82.1
Bath (England) 145 69.65±7.10 62.8 91.6
Leipzig (Germany) 354 72.73±8.65 46.7 63.4
Barcelona (Spain) 271 71.96±7.44 59.4 67.4
Copenhagen (Denmark) 384 72.35±8.29 49.9 81.7
Paris (France) 164 76.65±8.39 47.0 65.8
Prague (Rep. Czech 325 71.36±7.72 59.7 61.1
Republic)
Budapest (Hungary) 333 78.30±8.68 69.1 42.9
Oslo (Norway) 324 75.14±8.01 52.7 88.2
Victoria (Canada) 202 72.93±8.25 54.0 84.4
Melbourne (Australia) 376 75.63±6.92 58.2 83.7
Seattle (USA) 295 72.00±8.35 58.0 73.9
Beer-Sheva (Israel) 250 70.32±7.58 66.1 81.3
Tokyo (Japan) 188 69.39±5.70 53.5 60.7
Umea (Sweden) 455 72.74±8.21 53.4 76.2
Guangzhou (China) - - - -
Hong Kong (China) - - - -
Porto Alegre (Brazil) 328 71.78±7.74 67.4 82.3
Montevideo (Uruguay) 248 73.19±7.08 72.6 78.0
Izmir (Turkey) 327 70.97±5.31 52.3 45.3
Geneva (Switzerland) 139 74.34±7.32 55.8 88.5
Vilnius (Lithuania) 342 68.66±6.67 69.6 57.0
Total 5566 72.52±8.01 58.8 71.5

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Note: * "Guangzhou and Hong Kong were not included.

Sex percentages varied, with a high percentage of women in centers in Edinburgh, Montevideo, Budapest,
Vilnius and Porto Alegre.In addition, health status also varied, which was mainly a function of the type of
assessment, i.e., assessment by the single variable on health status or by diseases in a checklist of chronic
complaints. In terms of the single subjective variable on health status; Bath, Geneva, Oslo, Victoria and
Melbourne showed a high proportion of people reporting good health on this variable (>83%), while Izmir,
Budapest and Vilnius had higher proportions of sick people (>40%).

Measures

The key instruments in the field study were the 26-item WHOQOL-BREF (WHOQOL Group 1998), the 33-item
WHOQOL-OLD interim questionnaire, and socio-demographic and health status questions. The WHOQOL-
BREF was used in the field study because its brevity allowed centers to include other means of measurement
according to local interests and local availability of questionnaires.

Table 4 - WHOQOL-OLD field study measurement instruments by center - Table 4 - WHOQOL-OLD field study
measurement instruments by center
Center WHOQOL FAAQ GDS SF-12
Questionnaires
OLD 100 BREF
Edinburgh (Scotland) * - * * * -
Bath (England) * - * * * -
Leipzig (Germany) * - * * * *
Barcelona (Spain) * - * * * *
Copenhagen (Denmark) * * * * * *
Paris (France) * - * * * *+
Prague (Rep. Czech * - * * * -
Republic)
Budapest (Hungary) * - * * * -
Oslo (Norway) * - * - GDS-15 -
Victoria (Canada) * - * * * *
Melbourne (Australia) * - * * *(14 variables only) *
Seattle (USA) * - * * GDS-15 -
Beer-Sheva (Israel) * - * * * *
Tokyo (Japan) * - * * *
Umea (Sweden) * - * * GDS-15 (plus 15) *
Guangzhou (China) * - * - - -
Hong Kong (China) * - * - - -
Porto Alegre (Brazil) * F241-4 * * * *
Montevideo (Uruguay) * - * * GDS-15 -
Izmir (Turkey) * - * * * -
Geneva (Switzerland) * - * * - -
Vilnius (Lithuania) * - * * * *

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Centers (n) 18 1 18 18 14 (+4) 11

Note: += Geneva only.
Summary of the results of the questionnaire development

The two studies presented illustrate the development of a complementary questionnaire to the WHOQOL
measures for use with older adults. The studies demonstrated the development of the questionnaire according to
the WHOQOL methodology (WHOQOL Group, 1998) where a simultaneous approach to model development is
employed (Bullinger et al., 1996), That is, the starting point for the WHOQOL methodology is an intensive
qualitative phase of cross-cultural focus groups conducted in 22 centers around the world for the WHOQOL-
OLD.The output from these focus groups was used to identify common themes and questions absent or poorly
addressed in the WHOQOL-100; these themes and questions were used to create a set of pilot items for testing in
older adults.

The work of the focus groups, in conjunction with the Delphi method and WHOQOL experts, suggested two
possible items to adapt the WHOQOL-100 for use with older adults. Some topics seemed to generate better
additional items, such as questions about respect for death and dying, while other aspects or items seemed to be
complementary to existing items within the WHOQOL-100, such as Sexual activity.

However, quantitative analyses suggested that it would be better to include the additional items as part of the
supplemental questionnaire, rather than using them to supplement or modify the score of an existing item; this
strategy was most clearly demonstrated by the Sexual Activity item, where the supplements were still
problematic and added little value to the existing item.The clearest demonstration of this strategy was the Sexual
Activity item, where the add-ons were still problematic and added little value to the existing item.Instead, a set
of variables focused on the item Intimacy rather than Sexual Activity, which was drafted and tested in the field
study phase, and is now included in the final version of the questionnaire as a separate item.In terms of
psychometric performance, the variables selected for the WHOQOL-OLD questionnaire demonstrated both good
classical and modern performance. The approach used demonstrates that both classical and modern methods can
be combined in such a way as to complement the development of the scale.Although the modern psychometric
methods used, such as the Rasch model, have been developed primarily for use with unidimensional ability
scales, their careful use with attitude scales provides a powerful methodology for the development of valid
comparable measures across key populations, especially from different cultures.

Final version of the WHOQOL-OLD questionnaire

The final version of the questionnaire contains six items of 4 items each; comparisons between the WHOQOL-
100 and WHOQOL-BREF used in the pilot study and the field study, respectively, suggest that the questionnaire
for older adults can be used in conjunction with the WHOQOL-100 or WHOQOL-BREF, whichever is most

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suitable for a study. The questionnaire score will then consist of the sum of the six item scores or, supported by
the existence of a higher order factor in the confirmatory factor analysis (CFA; see below), a total individual
score can be had based on the sum of the 24 questionnaire items.

Scaled structure

The WHOQOL-OLD questionnaire consists of 24 Likert scale items attributed to six items: "Sensorimotor
Functioning" (FS), "Autonomy" (AUT), "Past, Present and Future Activities" (PTT), "Social Participation"
(OSP), "Death and Dying" (MEM) and "Intimacy" (INT).Each of the items had 4 items; therefore, for all items,
the score of possible values could vary from 4 to 20, provided that all items of an item were answered (see Table
5).The scores of these six items or the values of the 24 items of the WHOQOL-OLD questionnaire can be
combined to produce a total ("global") score of quality of life in older adults, such as the "total score" of the
WHOQOL-OLD questionnaire.As shown empirically through measurement model analysis using structural
equation modeling (see below), quality of life is conceived as a higher-order factor underlying the structure of
the WHOQOL-OLD questionnaire.

Table 5 - Variables included in the phases of the WHOQOL-OLD questionnaire

Items Acrony 3 items line items Possible range of total score
m
(min, max)
Skills FS 4 1+2+10+20 16 (4, 20)
sensory
Autonomy AUT 4 3+4+5+11 16 (4,20)
Past activities,
Present or future. PPF 4 12+13+15+19 16 (4,20)
Participation
social PSO 4 14+16+17+18 16 (4,20)
Death and dying MEM 4 6+7+8+9 16 (4,20)

Table 6 describes the main content areas of each WHOQOL-OLD questionnaire. The "sensory functioning" item
assesses sensory functioning and the impact of the loss of sensory abilities on quality of life.The item
"autonomy" refers to independence in old age and thus describes the extent to which one is able to live
autonomously and make one's own decisions. The "Past, present and future activities" item describes satisfaction
with life achievements and things that are desired. The "Social participation" item describes participation in daily
activities, especially in the community.The item "Death and dying" refers to concerns, worries and fears about
death and dying, while the item "Intimacy" assesses the ability to have personal and intimate relationships.

Table 6 - Concepts and contents of the items included in the WHOQOL-OLD questionnaire
Items Acro Concept/Content

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nym
Sensory skills FS Sensory functioning, impact of loss of sensory abilities on quality
of life.
Autonomy AUT Independence in old age, capacity or freedom to live
autonomously and make decisions.
Past, present and future
activities PPF Satisfaction over life's triumphs and things you long for.
Future
Social Participation PSO Participation in daily activities, especially in the community.
Death and dying MEM Concerns, worries and fears about death and dying.
Privacy INT Ability to relate personally and intimately.

Score

To correctly score the questionnaire, the following scoring checklist has to be administered (see Table 7).

(a) Basically, high scores represent high quality of life, low scores represent low quality of life;

(b) Rating of the items on appropriate scales. For positively expressed items, the above rating can be applied,
with higher values representing better quality of life. For negatively expressed items, the result has to be recoded
(see below);

(c) Recoding of negatively expressed items, i.e., each item identified with an "*" in the score list has to be
recoded so that the assigned numerical values are reversed: 1 = 5, 2 = 4, 3 = 3, 4 = 2, 5 = 1.Upon recoding, high
scores on positively expressed items reflected a better quality of life. The one-way values can be added later to
produce the summed scores according to the WHOQOL-OLD questionnaire score list (Table 7);

(d) The use of the scoring list (see below) is also necessary to identify which items belong to a heading. The
items to be recoded (see step c) will be marked with an asterisk;

(e) The sum of the items belonging to an item yields a net item score (EBF). Its range is between the lowest
possible value (number of items (n) x 1) and the highest possible value (number of items (n) x 5) of the
respective item.For the WHOQOL-OLD questionnaire, each of the six items includes 4 items, so the lowest
possible and highest possible score values are the same for all items (range 4 to 20);

(f) Comparison of the scores between the items is possible by comparing them directly with the net scores of the
items. Since all items include 4 items with the same scoring and ranking format, no transformation of net scores
(once all items per item have been answered) is necessary;

(g) In case the net item score is divided by the number of items in the item, the standardized (mean) item score
(EPF) can have any decimal value between 1 and 5.A value of 1 represents the lowest possible quality of life
assessment and a value of 5 represents the highest possible quality of life assessment for the individual;

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(h) The transformation of a net score, for a score transformed to the scale (ETE) between 0 and 100, makes it
possible to express a score in percentage between the lowest possible value (0) and the highest possible value
(100).To obtain the transformed score of the item (ETF) (0-100), the following transformation rule can be
applied: ETF = 6.25 x (EBF-4).

(i) The production of the WHOQOL-OLD total score involves the addition of item scores from a respondent
answering all items (rather than single-item items) of the questionnaire; (but if attention is paid to the recoding
procedure - see steps "b" and "c").(but if attention is paid to the recoding procedure - see steps "b" and "c")the
items can be aggregated to form a total score (as in step "e", but using all items), a standardized total (mean)
score (as in step "g", but using all items), or a total transformed score (0-100) (as in step "h", but using all items).

j) Accumulating the values of more than one person - for example, a given age group - can be done simply by
summing the item scores and/or total scores of each individual in that sample (at the net, mean, standardized or
transformed score level) and dividing the result by the number of its participants to produce the total average for
the corresponding group.

The above manual scoring method can be facilitated by the use of a scoring table that can be easily obtained
from the scoring list (see step "d").In addition, the SPSS syntax file (available separately) can be used for
automatic calculation of total item scores.To work with these, the individual data must be inserted into the
computer and identified through various names and labels, which are also proposed for the included program.
When analyzing the WHOQOL-OLD questionnaire, the item scores and total scores can be calculated according
to the following list (including the variable numbers for the WHOQOL-OLD questionnaire; see Table 7).

Table 7 - List of scores for the WHOQOL-OLD questionnaire.

Sensory Functioning (FS) old_01*old_02*old_10*old_20
4 items
Autonomy (AUT) old_03 old_04 old_04 old_05
4 items old_05 old_11

Past, present and future activities old_12 old_13 old_15 old_19

(PPF) 4 items old_19

Social participation (PSO) old_14 old_16 old_17 old_18

4 items old_18

Death and Dying (MEM) old_06*old_07*old_08*old_09

4 items
Intimacy (INT) old_21 old_22 old_23 old_24
4 items old_24

Total score (OLD) old_01*old_02*old_03 old_04

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24 items

old_05
old_06*old_07*old_08**
old_09*old_10*old_11 old_12
old_13 old_14 old_14 old_15
old_16 old_16
old_17 old_18 old_19 old_20
old_20
old_21 old_22 old_23 old_24
old_24
Note: *variables with inverted scores.

Interpretation

The values obtained for the individual WHOQOL-OLD questionnaire item scores and the total WHOQOL-OLD
score represent an empirical assessment of the quality of life of older adults from the perspective of the
questionnaire.Nationally representative data from standard samples are available for the WHOQOL-OLD
questionnaire, the results of the WHOQOL-OLD field study (n = 5566) should be used as preliminary reference
data for the elderly (60 years and older). For the reference values of WHOQOL-OLD item scores and total
scores, all scores were linearly transformed into a range from 0 to 100.

How to use the questionnaire

Upon completion, the completion of the questionnaire should be checked and the form identification recorded.
The use of the data for research purposes is not recommended when more than 20% of the items are missing (see
WHOQOL group, 1998a.1998- b).Data can be entered into the computer to facilitate scoring (in research
projects) or manual scoring can be performed according to the scoring procedure described above. The
questionnaires are available in the different project languages. The WHOQOL-OLD instrument in Portuguese
can be found in a separate file.

Recommended uses for application

The WHOQOL-OLD questionnaire can be used in a wide variety of studies including cross-cultural research,
population epidemiology, health monitoring, service development and clinical intervention studies where quality
of life questions are crucial.The WHOQOL-OLD questionnaire will allow the assessment of the impact of
service delivery and different health and social care structures on quality of life, especially in the identification
of the possible consequences of health and social care policies on quality of life.The WHOQOL-OLD
questionnaire will allow the assessment of the impact of service delivery and different health and social care
structures on quality of life, especially in identifying the possible consequences of policies on the quality of life
of older adults; and a clearer understanding of the areas of investment for better quality of life

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 MANUAL DEL CUESTIONARIO WHOQOL-OLD

outcomes.Estimating the impact of physical and psychological interventions on a range of physical and
psychiatric problems related to aging can be evaluated.Cross-sectional studies across different services or
treatments and longitudinal studies of interventions can be evaluated with the WHOQOL-OLD. In addition, the
unique cross-cultural focus of the instrument's development means that comparisons can be made across
different cultures (Power et al., 1999), The exacting standards of instrument development used for the
WHOQOL-OLD mean that such comparisons are of less risk of cultural bias; the WHOQOL methodology
(WHOQOL Group 1998-b) offers an appropriate approach to instrument development that provides cross-
cultural validity for quality assessment of older adults.

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