160 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 11, No.

4, 1998aZYXW

O rig in a l A rticles

WHOQOL-Hindi: A questionnaire for assessing quality of

life in health care settings in India
S. SAXENA, K. CHANDIRAMANI, R. BHARGAVA

ABSTRACT indirect effects of disease and treatment on individuals. QO L also

Background.ZYXWVUTSRQPONMLKJIHGFEDCBA
Q u a lity o f life is b e c o m in g a n im p o rta n t helps in policy research including programme evaluation and
com ponent o f o v e ra ll a s s e s s m e n t in h e a lth c a re s e ttin g s . H o w e v e r, resource allocation. 14,15
s a tis fa c to ry in s tru m e n ts a re n o t a v a ila b le fo r u s e in In d ia . Quality of life assessments have been used most widely in the
Methods. Q u a lita tiv e a n d q u a n tita tiv e w o rk w a s c o n d u c te d area of malignancies 16-18 though now their use has become common
a t th e D e lh i c e n tre a s a p a rt o f th e W H O Q O L (W o rld H e a lth in a number of other diseases and conditions including diabetes, 19.20
O rg a n iz a tio n Q u a lity o f L ife ) p ro je c t a t 1 5 c e n tre s In d e v e lo p in g hypertension.Pt-" chronic diseases such as arthritis and bron-
and d e v e lo p e d c o u n trie s to c o n s tru c t a new q u a lity of life chitis,23-25mental illnesses, 26-29
substance abuse, 30cerebrovascular
in s tru m e n t (W H O Q O L ). T h e p ilo t fie ld tria l a t D e ih l w a s c o n - disease," renal disease.v-" head injury ,34and old age. 35
d u c te d o n 3 0 4 a d u lt s u b je c ts u s in g th e 2 3 6 -lte m q u e s tio n n a ire . Most instruments used for assessing QOL were constructed in
Results. B a s e d o n th e p ilo t fie ld tria l d a ta , ite m re d u c tio n the developed countries of North America and Europe" and their
c o u ld b e d o n e to d e v e lo p a 1 O O -Ite m v e rs io n (W H O Q O L -l 00, cross-cultural compatibility has not been demonstrated. This
H in d i). T h e ite m s a re d is trib u te d in to 4 d o m a in s (p h y s ic a l; p s y - makes their direct application in developing countries questionable.
c h o lo g ic a l, s o c ia l a n d e n v iro n m e n ta l h e a lth ) a n d 2 5 fa c e ts . E a c h Adaptation and translation of these instruments for use in diverse
fa c e t h a s fo u r ite m s , ra te d o n a fiv e -p o in t s c a le . T h e in itia l p s y c h o - -cultural and linguistic settings poses serious methodological
m e tric p ro p e rtie s o f th is in s tru m e n t a re s a tis fa c to ry . A 2 6 -ite m problems.":" Simultaneous development in different cultures
s h o rt v e rs io n h a s a ls o b e e n d e v e lo p e d (W H O Q O L -B re f, H in d i). and languages has been suggested as an appropriate method for
Conclusion. T h e W H O Q O L -l 00, H in d i a p p e a rs to b e a ensuring cross-cultural applicability. 39.41
s u ita b le in s tru m e n t fo r c o m p re h e n s iv e ly a s s e s s in g q u a lity o f life in QOL assessment has been extremely rare in India.42-44One of
h e a lth c a re s e ttin g s . W H O Q O L -B re f, H in d i c a n b e u s e d fo r in te r- the important reasons for this is non-availability of a suitable
v e n tio n s tu d ie s in c lu d in g d ru g tria ls . instrument. The subjective Well-being Inventory" has been
developed as a QOL instrument in India, but it appears to be more
N a tl M e d J In d ia 1998; 1 1 : 1 6 0 -6 suitable for the general population than for ill patients seen in
health care settings.
INTRODUCTION
This paper presents the process involved in developing a QOL
Diseases affect human life in a profound way. They cause premature instrument (WHOQOL-Hindi) in collaboration with the WHOQOL
death resulting in decreased 'quantity' oflife, but more often they Group, Division of Mental Health and Prevention of Substance
cause structural and functional limitations that may seriously Abuse, World Health Organization, Geneva. The WHOQOL was
affect the 'quality' of life. Death is easier to identify and record; developed simultaneously in 15 centres across the world. Common
hence mortality has been a standard method for quantifying the elements of methodology and results are described in detail in a
impact of diseases. Quality of life (QOL) has been difficult to series of papers by the WH OQO L Group. 13.46-54 The present paper
measure, hence its use in health care settings has been comparatively focuses specifically on the work done at the Delhi Centre, which
recent. led to the development ofWHOQOL-Hindi.
Assessment of QO L has several uses in heal th care. It provides
a measurement of functioning and well-being rather than of The co n cep t a n d d efin itio n
diseases and disorders, hence is more comprehensive and com- There has been lack of clarity in the concept of QOL, with differ-
patible with the WHO's (World Health Organization's) concept ent groups of workers using the term in widely different ways. 14.55.56
of health. 1It can guide appropriate management strategies-! and There is also some overlap between functional status, health
also act as one of the outcome measures for comparing them,"? status, subjective well-being, health-related QOL and subjective
including drug trials+" QOL assessment focuses attention on QOL. WHO has defined QO L as 'individuals' perceptions of their
aspects of a patient's life beyond symptoms and signs. It thus position in life in the context of the culture and value systems in
sensitizes health care personnel to look for and correct direct and which they live and in relation to their goals, expectations,
standards and concerns'. 49It is believed to be a broad concept
All India Institute of Medical Sciences, New Delhi 110029, India incorporating in a complex wayan individual's physical health,
S. SAXENA, K. CHANDIRAMANI, R. BHARGAVA
Department of Psychiatry
psychological state, level of independence, social relationships,
personal beliefs and her/his relationships to salient features of the
Correspondence to S. SAXENA
environment. The definition highlights QOL as a subjective self-
© T h e N a tio n a l M e d ic a l J o u rn a l o f In d ia 1 9 9 8
SAXENAaZYXWVUTSRQPONMLKJIHGFEDCBA
e t a t. : WHOQOL-illNDI: QUALITY OF LIFE ASSESSMENT 161

report from the individual which is not based on reports or judg- The' global question pool' of some 1800 items was reduced to
ment from others (e.g. family members, clinicians). QOL is also a set of 1000 items, after excluding duplicate and semantic
multidimensional, incorporating positive (e.g. feeling happy, equivalent questions. These questions were rank ordered for each
contented, energetic) as well as negative aspects (e.g. not having facet according to 'how much it tells you about a respondent's
pain, sadness, sexual difficulties). QOL in your culture' . Questions were further eliminated from the
Though consequences of disease affect QOL in a major way, combined ranking for all centres.
these are not themselves assessed while measuring QOL. Only the Similar care was taken to generate cross-culturally comparable
effects of these symptoms on a person's life are assessed. This response scales. Each item was rated on a 5-point response scale
method of measuring QOL by generic questionnaires is concep- concerned with intensity (not at all-extremely), capacity (not at
tually more sound because a number of mediating factors determine all-completely), frequency (never-always) and evaluation (very
how much and what kind of effects a disease will have on a satisfied-very dissatisfied, very good-very poor). Although end-
person's QO L. These factors include personal and environmental points (e.g. never-always) are relatively universal, ambiguity and
contextual variables. For example, a knee injury may limit joint cultural variations exist for intermediate responses. Descriptors
movement. For a young man whose aim in life is to become a were derived to find words/terms falling at 25 %, 50 % and 75 %
professional football player, this disability seriously affects his positions between the two end-points. Details of these exercises
QOL. But for another person whose profession involves mainly have been described elsewhere. 53
reading and writing, the same disability affects the QOL to a lesser
extent. Hence, a QOL questionnaire aims to assess the extent to T h e p ilo t fie ld tria l
which significant aspects of a person's life have been affected, The pilot instrument contained 236 questions covering 6 domains
rather than what symptoms and disabilities are present. This and 29 facets of QOL. This was based on approximately 8 ques-
concept of measuring QOL also makes it easier to construct a gen- tions per facet; 4 'perceived objective' questions and 4 'self-
eric instrument that can be applied to individuals suffering from report subjective' questions. Some of these questions were genera-
illnesses of diverse nature and severity, than to devise an instrument ted at the Delhi centre and were in Hindi. Others were translated
for each condition separately. into Hindi according to the WHOQOL translation methodology.ZYXWVUT57

In addition, 21 national questions were incorporated in the

METHODS instrument (Table I). These questions were selected from a larger
D e v e lo p m e n t o f W H O Q O L list ofitems developed at the Delhi centre. The items were thought
P re p a ra to ry w o rk . Each step involved in the development of to be culturally relevant but could not be included in the
WHOQOL was carried out simultaneously in many centres of the international pilot version.
world. These IS field centres (from developing and developed A cross-sectional design was used to field-test the pilot
countries) were selected to take into account the variations in questionnaire on at least 300 subjects in each field centre. At the
different cultures (e.g. level of industrialization, available health Delhi centre, 304 adult subjects were drawn from the Hindi-
services, etc.).
The first step consisted of establishing an agreed upon definition TABLEI. List of national questions
ofQOL. Important characteristics ofQOL construct were identified,
1. To what extent have you achieved your desired position in life?
with special emphasis on cultural relevance. A list of domains and
2. How much do you worry about your health?
facets were then drafted by each centre. Six broad domains were
3. How satisfied are you with your ability to fulfil the sexual needs of
identified which describe core aspects of QOL cross-culturally your life partner?
(physical, psychological, level of independence, social relation- 4. How satisfied are you with the number of children you have?
ships, environment and personal beliefs/spirituality). Domains 5. How satisfied are you with your children being sons or daughters?
were further classified into a number offacets, e.g. psychological 6. Do you feel yourself a burden on others?
domain included facets that assess positive feelings, body image, 7. How satisfied are you with the complexion of your skin?
self-esteem, thinking, memory and concentration, and negative 8. To what extent are you fed up with life?
feelings. Facets describe behaviour (e.g. personal relationships), 9. To what extent do you feel guilt and remorse?
states of being (e.g. fatigue), capacities (e.g. ability to move 10. Does expenditure on medicines cause you financial difficulty?
about) or subjective perceptions of experiences (e.g. pain). 11. Does expenditure on tobacco, alcohol or intoxicating drugs cause
you financial difficulty?
The next stage involved group interviews (focus groups) with
12. To what extent are you able to express the feelings of your mind in
patients, well persons and health personnel in each of the field front of others?
centres, to evaluate the appropriateness of the facet definitions 13. To what extent do you feel yourself an integral part of your family?
drafted by health professionals and QOL researchers. Based on 14. How satisfied are you with the way responsibilities are shared within
these reports, the facet definitions were revised. Questions were your family?
drafted by focus groups. Thus ideas were generated, within each 15. To what extent do you remain worried about your family?
centre, as to how and in which form questions relating to QOL 16. To what extent can you fulfil the needs of your family?
should be asked. Following the focus group work, a question 17. To what extent do you have to ignore your own needs for the sake of
writing panel in each centre framed a maximum of six questions others?
in their own language. This process ensured that the questions 18. How satisfied are you with your capacity to bear sudden major
expenses?
were raised by both health personnel and patients in each of the
19. To what extent are you able to get essential medical services with
centres. A conceptual distinction was made between two types of the money available with you?
questions: 'perceived objective questions', i.e. global evaluation 20. To what extent does lack of cleanliness in your physical
of functioning (e.g. How well do you sleep?) and 'self-report environment distress you?
subjective questions' i.e. perceived satisfaction/dissatisfaction 21. To what extent do your religious beliefs come in the way of your
with functioning (e.g. How satisfied are you with your sleep?). desired activities?
162 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 11, NO.4, 1998

speaking population; the size being based on the required number significant or negative correlations in any centre were excluded
of subjects per cell (generated by the sampling quota) needed for (with one or two exceptions). In the Delhi data, 24 items had
analysis of the pilot data. The sampling quota was as follows: low correlations ( < 0.40).
6. Validity problem. Twenty-four items were eliminated as they
1. Age (50% ~45years, 50% 2.45 years)
failed to distinguish significantly between the 'sick' and 'well'
2. Sex (50% male, 50% female)
respondents. In the Delhi data, only one item failed to discrim-
3. Health status (250 persons with disease or impairment; 50 well
inate between the two groups and was eliminated.
persons)
The analyses did not suggest that the national questions per-
Purposive sampling was followed in data collection and the
formed better than the general questions and hence were eliminated.
sample was not representative of the patient and healthy population
Five problematic facets (activities as provider/supporter, sensory
atthe centre. Of 304 adult subjects, 50.7 % were males. The mean
functions, dependence on non-medical substances, communication
(SD) age of the sample was 40.7 (14.3) years. Two hundred and
capacity and work satisfaction) were identified and dropped.
fifty-three persons comprised the 'unwell' group. Persons with
Some facets were excluded because responses to these items
illness or impairment were outpatients and inpatients from medical
were highly skewed (activities as provider/supporter, dependence
and surgical departments of the All India Institute of Medical
on non-medical substances, and communication capacity). Further,
Sciences (AIIMS), with problems ranging from very mild (e.g.
in facet activities as provider/supporter, nearly half the items
fever.headache, etc.) to severe (e.g. malignancies, renal failure,
showed reliability problems. Two items correlated well with
etc.). Patients with neurological and psychiatric illnesses were not
another facet (personal relationships) and hence were moved to
included in the sample. Fifty-one' well' respondents were recruited
this facet. Communication capacity also had reliability problems
from amongst the relatives of the patients in the hospital and the
(low item-total correlation and facet-domain correlation). Sensory
general community.
function was dropped primarily due to low facet-domain correla-
The instrument was largely self-administered. The subjects
tion. Items of work satisfaction facet discriminated poorly between
who were illiterate or had a disability that interfered with self-
'sick' and 'well' persons. Some of these items also had problems
administration of the questionnaire, were administered the
of low correlations (facet-domain correlations and items-global
WHOQOL as a structured interview. The subjects were assessed
QO L correlations).
cross-sectionally. Forty-one questions concerning perceived
Though some of the facets (e.g. sensory functions, communi-
importance of facets were also asked in a separate questionnaire
cation capacity) are likely to be important for assessing QOL, the
to the same respondents.
items of these facets could not compete with other items in the
RESULTS global pool. Hence, they were excluded from the generic version
of the core instrument and for having poor psychometric properties.
The data obtained from the New Delhi centre as well as other
Nevertheless, these items are being explored in add-on modules
centresCBA
( n =4802) were analysed with the aim of striking a balance
that are being developed for assessing people with specific
between a minimum number of facets/questions and adequate
conditions/situations/diseases (HIV, cancer, refugees, informal
coverage of key areas across cultures. The selection of items was
.care-givers, individuals with communication difficulties, etc.) in
based on the analyses done at the level of individual field centres,
which the core module does not provide sufficient detail. For
summaries across centres and at the level of the pooled global
example, the items of sensory functions were thought to be perti-
data.
nent in the elderly group. Items related to activities as provider/
The analyses carried out at item, facet and domain level for
supporter may be explored in the 'carer group'.
elimination/selection of items/facets is briefly summarized below:
Thus, the analyses of the WHOQOL pilot data eliminated
1. Frequency problem. Items that had two or more adjacent some items and facets, resulting in the development of the
scale points showingZYXWVUTSRQPONMLKJIHGFEDCBA
< 10 % of the response were deleted. Such WHOQOL field trial form comprising 100 questions grouped into
problems were present in 43 items. six domains.
2. Reliability problem. Problems of low item-total correlation Further, multivariate analyses were carried out to confirm the
( < 0.40) with their own facets led to the deletion of that item. domain and facet structure of the WHOQOL-100. It also examined
Eleven items had a reliability problem. whether this universal structure could describe most aspects of
However, these items were eliminated only if they had people's QOL.
problems in the global analyses or in at least 8 centres. Earlier exploratory and confirmatory factor analyses carried
3. Overlapping. Fifteen items which overlapped conceptually out on the global data (using structural equation modelling 59)had
with other items were deleted. shown the comparative fit index (CFI) for single-factor model and
4. Multitrait analysis programme (MAP) problems. MAP six-domain model to beO.875 andO.888, respectively (CFI> 0.9
analysis" was carried out in order to identify items that had is considered to be a good degree of fit). Analyses (on new global
higher loadings on another facet rather than on its own predicted data sets) also provided some evidence that a four-domain solution
facet. No item showed this pattern. However, 7 items that were may be the most appropriate (CFI=0.901).54 The four-domain
highly loaded (r > 0.40) on more than one facet were identified structure was obtained by merging physical health with the level
and 6 finally eliminated. of independence; and psychological with spirituality domain.
Facet and domain inter-correlations were examined. Sexual Similar analysis of the Delhi data for four-domain structure
activity of the physical domain was moved to the social indicated the CFI to be 0.876 (Table II). By allowing error
relationship domain. Facets were found to be fairly independent variances to covary for the environment and social relationships
of each other. domains, the CFI increased to 0.991, thereby improving the fit
5. Re-analysis for reliability (item-total facet correlation) index and indicating acceptability of the model in the Hindi-
problem in each centre. Eleven items that showed non- speaking population. In addition, when each of the domains of
SAXENAaZYXWVUTSRQPONMLKJIHGFEDCBA
et a l. : WHOQOL-HINDI: QUALITYOF LIFE ASSESSMENT 163

TABLEII. Multivariate analyses for confirmation of domain TABLEIII. Mean scores and Cronbach alphas of facets of the
structureofWHOQOL-lOO, Hindi (n = 3 0 4 ) WHOQOL-lOO, Hindi
Domain CFI Regression coefficients No. Facets Mean (SO) Cronbach alphaCBA
Physical 0.957 0.253 O v e r a ll q u a lity o f life a n d g e n e r a l h e a lth 13.3 (3.5) 0.81
Psychological 0.982 0.267 1.
Pain and discomfort 11.1 (3.7) 0.72
Social relationships 0.971 0.219 2. Energy and fatigue 12.6 (3.9) 0.73
Environment 0.922 0.157 3. Sleep and rest 14.5 (3.6) 0.76
------------------- 0.876* 4. Positive
51.9tZYXWVUTSRQPONMLKJIHGFEDCBA feelings 11.8 (3.3) 0.63
5. Thinking, learning, memory and 14.0 (3.1) 0.69
* Comparative Fit Index (CFI) at domain level concentration
t Adjusted R2; 'overall quality of life and general health' facet score as 6. Self-esteem 14.2 (3.3) 0.66
dependent variable and domain scores as independent variables. 7. Bodily image and appearance 15.2 (3.4) 0.59
8. Negative feelings 10.7 (3.8) 0.85
9. Mobility 14.1 (4.5) 0.91
WHOQOL-lOO, Hindi were analysed separately keeping only 10. Activities of daily living 13.4 (3.6) 0.74
one factor upon which all facets loaded, the CFI on all the four 11. Dependence on medication or 11.1 (4.0) 0.76
domains ranged between 0.922 (environment domain) to 0.982 treatment
(psychological domain) (Table II). Further analyses to assess 12. Working capacity 13.1 (4.4) 0.90
other possible structures on new data sets using WHOQOL-lOO, 13. Personal relationships 15.1 (3.0) 0.67
Hindi are required. 14. Social support 13.4 (3.5) 0.77
Multiple regression analyses confirmed the four-domain struc- 15. Sexual activity 13.1 (3.5) 0.60
ture (R2 = 51. 9) ofWH OQO L-l 00, Hindi with each domain contri- 16. Physical safety and security 13.7 (3.5) 0.76
17. Home environment 14.4 (3.2) 0.75
buting significantly towards the regression equation (Table II).
18. Financial resources 12.8 (3.9) 0.82
The psychometric properties of the WHOQOL-lOO, Hindi
19. Health and social care; availability 13.6 (2.7) 0.63
were examined following a series of subscale reliability analyses, and quality
and item, facet and domain correlation analyses. Cronbach alpha 20. Opportunities for acquiring new 13.2 (3.3) 0.77
was found to be moderately high for most of the facets (Table III). information and skills
All facets correlated significantly with their respective domains. 21. Participation in and new 12.3 (3.3) 0.70
All the facets and domains also correlated significantly with the opportunities for recreation/leisure
overall QO L score ranging from r = 0 .18 (environment) to r = 0.65 22. Physical environment 13.3 (2.9) 0.62
(psychological). In addition, all items distinguished significantly (pollution/noise/traffic/c1imate)
between the 'diseased' and the 'healthy'. 23. Transport 12.8 (3.3) 0.67
24. Spirituality/religion/personal beliefs 13.5 (3.5) 0.82
Thus, the series of analyses at different levels refined the
structure of the pilot form into WHOQOL-lOO that had satisfac-
tory psychometric properties. TABLEIV. The WHOQOL-IOO facets and domains
S tru ctu re o fW H O Q O L -IO O Domain Facets incorporated within domains
The WHOQOL-l00, Hindi instrument encompasses 24 facets and Physical health Activities of daily living
one general facet that questions overall QOL and health. Each Dependence on medicinal substances and
facet is represented by four questions. These facets are grouped medical aids
into 4 large domains: physical, psychological, social relationships Energy and fatigue
and environment (Table IV). Mobility
The period of reporting for all questions is two weeks. This is Pain and discomfort
mentioned in the scale at the beginning of each section (a total of Sleep and rest
Work capacity
eight times) to ensure that the respondents kept the time-frame of
Psychological Bodily image and appearance
two weeks in mind while responding to each item. Negative feelings
All items are rated on a five-point scale (1-5). The WHOQOL- Positive feelings
100, Hindi produces individual facet scores (e.g. positive feeling Self-esteem
score, social support score, etc.), domain scores (e. g. psychological Spirituality/religion/personal beliefs
domain score) and a score relating to overall QOL and general Thinking, learning, memory and concentration
health. Social relationships Personal relationships
Social support
S tru ctu re o f W H O Q O L -B ref, H in d i Sexual activity
Environment Financial resources
Although the WHOQOL-lOO provides a comprehensive
Freedom, physical safety and security
assessment of QOL, its length can limit its use. As a result, an Health and social care: Accessibility and quality
abbreviated version (WHOQOL-Bref, Hindi) of 26 items was Home environment
developed using data from the field-trial version of the WHOQOL- Opportunities for acquiring new information
100. The WHOQOL-Bref contains two items from the overall and skills
QOL and general health, and one item from each of the remaining Participation in and opportunities for reception/
24 facets included in the WHOQOL-l00. (T h e W H O Q O L -IO O leisure activities
a n d W H O Q O L -B ref q u estio n n a ires a lo n g w ith d eta ils o f in stru c- Physical environment (pollution/noise/traffic/
tio n s, h ea d ers, q u estio n o rd er, resp o n se sca le a n d sco rin g m eth o d climate)
a re a va ila b le fro m th e co rresp o n d in g a u th o r.) Transport
164 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 11, NO.4, 1998

WHOQOL-Bref, Hindi produces an aggregate score and four Besides use in research studies, WHOQOL can be used in
domain scores but does not provide individual facet scores. clinical practice to determine the impact of disease, disability and
Domain scores produced by the WHOQOL-Brefhave been shown treatment modalities on patients. Specific modules that are being
to correlate at around 0.9 with the WHOQOL-1 00 domain scores, developed as a supplement to the core instrument are likely to lead
and hence provide an excellent alternative to the assessment of to a greater understanding of the diverse effects of diseases experi-
domain profile using WHOQOL-100. The brief scale is also likely enced by the patients on their lives. They may also guide towards
to be useful in busy clinics and wards since it takes only 5-8 better and more comprehensive management strategies, including
minutes to complete. It can also be conveniently used in studies psychosocial interventions.
which assess QOL longitudinally at several time intervals. In contrast to many other QOL instruments, WH OQO L includes
The scale has been shown to have good discriminant validity, a domain on environment. This is considered necessary as environ-
sound content validity and good test-retest reliability at several ment plays a major role in determining health states, mediating
international WHOQOL centres. Despite the heterogeneity of disease pathogenesis and limiting or facilitating access to health
facets included within domains, all domains display excellent care. Like all other domains in WHOQOL, environment domain
internal consistency. Acceptable comparative fit indices were is also assessed by a subjective self-report with the underlying
achieved when the data from original pilot, field trial and new belief that even if subjective reports are at variance with objective
centres (CFIZYXWVUTSRQPONMLKJIHGFEDCBA
= 0.906, 0.903 and 0.87 , respectively) were applied to reality, it is the former that determines QOL.
the four domain structures using confirmatory factor analysis. Since WHOQOL has been developed simultaneously in many
When three pairs of error variances were allowed to covary (i.e. centres across the world and the different language and national
Pain and dependence on medication, Pain and negative feelings, versions are compatible and comparable with each other, multi-
Home and physical environment) and two items were allowed to centre international studies can be conducted using this instrument.
cross-load on other domains (i.e. safety on the global domain and In India, besides Hindi, a version in Tamil is available and a ver-
medication negatively on the environment domain), the CFI of sion in Kannada is being developed. WHOQOL cannot be used in
new data also increased to 0.901.54 other languages after simple translation, but fresh versions can be
developed (e.g. for other regions of India) using the WHOQOL
DISCUSSION methodology. 54 This includes preparatory qualitative research
Quality of life is often regarded as a concept that is too nebulous followed by a pilot field trial to ensure cultural and linguistic equi-
to be measured reliably with a structured questionnaire and is valence of different versions.
subject to too much variability across cultures and individuals to Although on initial assessment, the psychometric properties of
have any useful validity. The WHOQOL project has shown that WHOQOL-100 and WHOQOL-Bref appear satisfactory, more
both these assumptions are incorrect. This international project studies are needed to determine the reliability, validity and res-
has demonstrated that QOL can be conceptualized and defined in ponsiveness to change of these questionnaires. These studies
a uniform way across cultures. Its constituent core domains and should preferably be from diverse clinical populations to ascertain
facets can be assessed using structured questionnaire methodology, the suitability ofWHOQOL-100, Hindi and its goodness of fit in
and cross-cultural as well as intra-cultural comparisons can be these settings. Large general population studies are also needed to
made. These developments are of major significance to health establish norms for comparison purposes.
care professionals, who aim not only to prevent and treat diseases WHOQOL-Brefprovides a shorter alternative to the assessment
but also to promote health and QOL. of QOL based on the WHOQOL domain profiles. However,
WHOQOL-Hindi is available in two versions, the long 100- analyses on varied data sets are required for replication of selection
item version (WHOQOL-100, Hindi) and the brief26-item version of items and their' goodness of fit' at the Delhi centre.
(WHOQOL-Bref, Hindi). The long version assesses QOL compre-
hensively and is a suitable instrument for use in studies' where ACKNOWLEDGEMENTS
QOL is the only or the main determinant. Since it gives a profile This work was done as a part of the WHOQOL Project of the Division of
of domain scores, effects of a disease or intervention on separate Mental Health and Prevention of Substance Abuse, World Health Organiza-
tion, Geneva. The authors acknowledge constant help extended by the
domains (e.g. physical v. psychological) can be studied. For
WHOQOL Group and particularly by Dr John Orley and Professor Mick
example, WHOQOL-100 may be suitable in a study which com- Power. Drs Sanjay Agrawal, Pratap Sharan, Anju Dhawan, Hemraj Pal and
pares the survival time and QOL of cancer patients on a new, more Dhanesh Kumar assisted in the work at New Delhi.
aggressive chemotherapy regimen compared to the standard
treatment. On the other hand, WHOQOL-Brefmay be useful in REFERENCES
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