Development and Psychometric Properties of the. World Health Organization Quality of Life Assessment Instrument (WHOQOL- 100) in Portugal

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1 Development and Psychometric Properties of the World Health Organization Quality of Life Assessment Instrument (WHOQOL- 100) in Portugal Abbreviated Title: Development of the WHOQOL-100 in Portugal Maria Cristina Canavarro 1, Adriano Vaz Serra 2, Mário R. Simões 3, Daniel Rijo 4, Marco Pereira 5, Sofia Gameiro 6, Manuel João Quartilho 7, Luís Quintais 8, Carlos Carona 9 & Tiago Paredes 10 1 Associate Professor. Faculty of Psychology and Educational Sciences. University of Coimbra. 2 Full Professor. Faculty of Medicine. University of Coimbra. 3 Full Professor. Faculty of Psychology and Educational Sciences. University of Coimbra. 4 Assistant. Faculty of Psychology and Educational Sciences. University of Coimbra. 5 PhD Student. Portuguese Foundation for Science and Technology (FCT - SFRH/BD/19126/2004). 6 PhD Student. Portuguese Foundation for Science and Technology (FCT - SFRH/BD/21584/2005). 7 Invited Professor. Faculty of Medicine. University of Coimbra. 8 Auxiliary Professor. Department of Anthropology. Faculty of Sciences and Technology. University of Coimbra. 9 Psychologist. Portuguese Association of Cerebral Palsy (NRC-APPC). 10 Psychologist. Master Degree in Psychological Assessment at Faculty of Psychology and Educational Sciences. University of Coimbra. Full address for correspondence: Maria Cristina Canavarro Faculdade de Psicologia e Ciências da Educação - Universidade de Coimbra Rua do Colégio Novo, Apartado COIMBRA Telephone: / Fax mccanavarro@fpce.uc.pt 1

2 Abstract Background: At the beginning of the 1990s the World Health Organisation (WHO) developed a project in order to create a cross-cultural instrument of quality of life assessment: the World Health Organisation Quality of Life (WHOQOL). Purpose: This paper describes the development of the European Portuguese version of the WHOQOL-100, according to the methodology recommended by the WHO. Method: Special attention is given to the qualitative pilot study, which led to the development of the Portuguese Facet [Political Power]; and to the empirical pilot study and the psychometric studies, based on the application of the Portuguese version of the instrument to a sample of 315 subjects from the general population and 289 patients. The assessment protocol also included the Beck Depression Inventory and the Brief Symptom Inventory. Results: The Portuguese version of WHOQOL-100 showed acceptable internal consistency ( range: ) and test-retest reliability in all domains (r range: ). Discriminant validity was significant for all domains, except in Spirituality. Convergent validity with the BDI and the BSI was satisfactory for most domains. Conclusion: The WHOQOL showed good psychometric characteristics, suggesting that the Portuguese version of WHOQOL is valid and reliable in the assessment of quality of life in Portugal. Keywords: Quality of Life; World Health Organisation; Assessment; Focus Groups; Psychometric studies. 2

3 INTRODUCTION The purpose of the present paper is to describe the development of the European Portuguese version of WHOQOL-100, following the methodology recommended by the World Health Organisation (WHO), and to present its psychometric properties. The expression quality of life (QoL) has been used much more frequently in the last decades. However, as a scientific concept it may appear ambiguous unless it is the object of a precise definition (Wolfensberger, 1994). There was been a proliferation of quality of life measures, many of which were not based on a conceptual framework, and the majority of which was developed in the USA and subsequently translated and applied to other cultures (Orley, 1994), providing versions that lack cross-cultural equivalence. In this context, at the beginning of the 1990s, the WHO brought together a group of experts from different cultures (WHOQOL Group) to discuss the quality of life concept and develop an instrument to assess it. In this process, the WHOQOL Group defined quality of life as the individual's perception 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 (1994a, p.28). Accordingly, the WHOQOL-100 intends to capture the individual s subjective perception of their quality of life in the context of the physical, cultural and social environment in which they live (WHOQOL Group, 1995). The various stages of the development of the WHOQOL-100 are described in various papers and documents published by the WHOQOL Group (WHOQOL Group, 1994a, 1994b, 1995, 1998). The contents and the organisation of items, facets and domains of the original version of the WHOQOL-100 were submitted to successive 3

4 procedures of revision and reflection, initially through qualitative, and later quantitative methodologies, until a conceptual structure that obtained international consensus was achieved (Skevington, 1999; WHOQOL Group, 1994). The multidimensional nature of the concept of quality of life adopted by the WHO led to a multidimensional quality of life assessment measure: the structure of the WHOQOL-100 is based on six general domains (Physical; Psychological; Level of Independence; Social Relationships; Environment; and Spirituality). Each domain is divided into a series of specific areas (facets) summarizing that particular domain of QoL (cf. Figure 1). A set of general questions about the subject s quality of life and health perception is also included. Each facet is assessed by four questions and answers to WHOQOL-100 questions are given on 5-point Likert-type response scales. Each scale point is indicated with a number and a verbal descriptor. The four developed response scales are concerned with Intensity (Not at all Extremely); Capacity (Not at all Completely); Frequency (Never Always); and Evaluation (Very dissatisfied Very satisfied; Very good Very poor). All facet and domain scores are transformed to reflect a 0 to 100 scale (a high score corresponds to a better QoL); there is no total score for the WHOQOL-100. Figure 1 Domains and facets of the WHOQOL-100, including the Portuguese facet, Political Power After the original version of the WHOQOL-100 was developed, new international centres, such as Portugal, were admitted to the project, so that the instrument could be used by an increasing number of countries and cultures. The 4

5 WHOQOL is presently available in more than 40 different languages (Skevington, Sartorius, Amir, & WHOQOL Group, 2004). Although aiming for the development of a cross-cultural instrument, the WHOQOL instruments can also incorporate national items (additional facets). This feature is not accommodated for in most generic QoL instruments and, in this way, the WHOQOL design is new. Introduction of national items is permitted within pre-agreed criteria, namely the process of framing questions (Skevington, Bradshaw & Saxena, 1999). For the present study we hypothesised that: (1) the perception of quality of life in WHOQOL domains and general facet is poorer among patients; (2) regarding the nature of diseases, Psychiatric patients will report the lowest scores in the Psychological domain, and the Physical and Level of Independence domains would be specially affected among patients from Rheumatology and Oncology; and (3) there is a significant negative association between QoL and depression and psychopathology. METHOD DEVELOPMENT OF THE EUROPEAN PORTUGUESE VERSION OF WHOQOL The WHO recommends a specific methodology for the validation of the WHOQOL family instruments at other international WHOQOL Centres. This methodology consists of four different steps: (1) translation of the instruments; (2) preparation of the pilot qualitative study; (3) development of the response scales; and (4) the quantitative study. 5

6 A version of the WHOQOL had already been developed for Brazilian Portuguese at the Brazilian Centre for Quality of Life, in Porto Alegre, supervised by Prof. Marcelo Fleck (Berlim, Pavanello, Caldieraro, & Fleck, 2005; Fleck, 2000; Fleck, Leal et al., 1999; Fleck et al., 2000; Fleck, Louzada et al., 1999). However, the language differences and the different cultural context led to the need to develop a different version of the instrument for European Portuguese. Specifically, the grammatical construction of sentences is different among these countries and this reflects on the words used in the translation of some expressions (e.g., How much...?; How satisfied?), not commonly used in Portugal, and this particular way of framing questions might be hardly understandable for the Portuguese population. The WHOQOL Group Coordinator, Prof. Somnath Chattergi, after our request to validate the instrument in Portugal, regarding the mentioned aspects, also considered the need to develop a European Portuguese version of WHOQOL-100. Bearing this in mind, professors and researchers from several faculties and departments of the University of Coimbra, together with some Masters and PhD students at the same University, created the team of the Portuguese WHOQOL Centre. In the validation of the European Portuguese version, the original English version was used, and all steps mentioned were followed (Canavarro et al., 2006; Rijo et al., 2006; Vaz Serra et al., 2006a, 2006b). In the present paper, we refer only the phases corresponding to the qualitative study (Step 2) and the field quantitative study (Step 4), due to their critical importance in the validation process of the WHOQOL-100. Qualitative Pilot Study: The Focus Groups and the Development of the Portuguese Facet (PF 25 - Political Power) 6

7 The main goal of the qualitative pilot study was to validate the general structure of the WHOQOL-100 for the Portuguese cultural context and, if pertinent, to allow the creation of additional questions assessing culture-specific issues. According to the recommendations of the WHO (WHOQOL Group, 1994a, 1995), in order to achieve this goal, the European Portuguese version of the WHOQOL- 100 was discussed in four focus groups: (1) people from general population, including informal caretakers mainly family members of patients (8 individuals, 4 of which were informal caretakers); (2) people with some contact with a healthcare service (2 patients from the Rheumatology Department and 4 patients from the Psychiatry Department of the University of Coimbra Hospitals); (3) Health professionals (2 psychologists, 1 medical doctor, 1 speech therapist, 1 social worker, and 2 nurses, from various healthcare institutions in the Coimbra region); and, (4) an additional group of psychological assessment professionals (15 students of the Master in Psychological Assessment at the Faculty of Psychology and Educational Sciences of the University of Coimbra). Each focus group met once, in a session of 90 to 120 minutes, divided in three different phases, with detailed orientation and instructions: (1) introduction to the discussion topic, without referring to theory details; (2) free discussion of the participants conception of quality of life; and (3) explanation and discussion of the concept of quality of life as proposed by the WHO. In every focus group, both in the free discussion (Part 2) as well as in the final discussion (Part 3), the multidimensional concept proposed by the WHO was corroborated. Interestingly, in all focus group, a proposal for a new aspect concerning the following topics came up: influence of the political measures and decisions in people s quality of life; increasing insecurity concerning the future as a result of the last 7

8 years political state of affairs; bad management of funds and financial resources by central and local administration and the subsequent interference in citizens quality of life (e.g., availability and quality of health services); and, finally, the powerlessness of the citizens to have real influence on what is decided and legislated. After carefully analysing the contents of the audio recordings of the sessions, transcribed verbatim by the Portuguese team, and in accordance with the WHO guidelines for the creation of new facets (WHOQOL Group, 1995), a new facet labelled PF 25 - Political Power was added to the instrument. Content analysis revealed four dimensions associated with Political Power (chance of participation; satisfaction with; impact of; and confidence in the decisions made by the politicians), and, for each of these, two questions were formulated, resulting in a set of eight new questions. Considering that each facet should be assessed throughout four questions, for selecting questions to assess PF 25, the following criteria were used: the internal consistency degradation method was chosen as the first selection criteria; then, the correlation of each item with the total of the new items was considered, and items with a correlation lower than.40 were excluded. Thus, the four most robust items were chosen to form the Portuguese Facet. Depending on the wording used, national items regarding the Political facet were attached to one of the possible response scales, and were added to the instrument at the end of the appropriate block. The four final questions that make up PF 25 are presented in Figure 2. Figure 2 Questions of the Portuguese Facet (PF 25 Political Power) 8

9 Empirical Study: Psychometric Properties of the European Portuguese version of WHOQOL-100 Sample characteristics. The WHO considers that a minimum sample size and sample diversity is necessary for the development of a generic health-related quality of life measure. Therefore, new field centres must administer the WHOQOL instrument to adults (with adult being culturally defined) and apply a specified sampling quota with regard to age (50% 45 years), gender (50% male and 50% female) and health status (250 persons with a disease or impairment and 50 healthy respondents). They are also instructed to recruit a sample of respondents that represent the health care users in their country or region and with a variety of diagnosis and varying degrees of severity of disease or disability (WHOQOL Group, 1998, p. 1571). Accordingly, the sample for the Portuguese national version of the WHOQOL included 604 subjects (289 patients and 315 controls), all adults, equally divided by gender and age (18-44; above 45 years), and with similar numbers of inpatients and outpatients. The mean age was years (SD=15.96). The sample characteristics are presented in Table 1. For methodological reasons, a larger sample of controls was enrolled (n=315). The clinical group (n=289) was recruited from the following departments of the Coimbra University Hospitals (CUH): Psychiatry (20.4%), Gynaecology (10.7%), Rheumatology (25.3%); 24.9% were recruited from Orthopaedics (CUH) and from Oncology (Portuguese Institute of Oncology); and the remaining 18.7% were recruited from Health Centres from Coimbra. To be eligible for the clinical sample, the patients must be receiving some form of medical care (in the case of outpatients, a physical examination or pharmacological treatment). 9

10 Table 1 Instruments. The assessment protocol, besides WHOQOL-100, also included the Beck Depression Inventory - BDI (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961; Vaz Serra & Pio Abreu, 1973a, 1973b), and the Brief Symptom Inventory - BSI (Canavarro, 1999; Derogatis, 1993) to assess depression and psychopathological symptoms, respectively. Statistical Analysis. Data analyses were carried out using the SPSS (Statistical Package for the Social Sciences), version Internal consistency reliability was assessed using Cronbach s. Test-retest reliability was evaluated by using Pearson s correlations coefficient and t-test for paired samples. Regarding discriminant analysis, Student t-tests and Analysis of Variance (ANOVA), with Bonferroni and Dunnett post hoc tests, were used. Construct and convergent validity was analysed by examining the structure of the Pearson correlation matrix obtained by relating the WHOQOL domains and the BDI and the BSI. RESULTS Internal Consistency. Reliability coefficients were calculated for the total score of the 25 facets (24 specific facets plus a general facet), for the total score of the 6 domains, for the 100 items of the WHOQOL-100, as well as for each domain individually. Results are shown in Table 2. 10

11 Table 2 Overall, the instrument demonstrated good indexes of internal consistency (all domains exceeding 0.80) considering the total score of the 25 facets, the 6 domains or the 100 questions that comprise the instrument. When analysed individually, all domains showed good Cronbach alphas, ranging from 0.84 (Spirituality) to 0.94 (Level of Independence). The alpha obtained for the general quality of life facet (not included in the overall WHOQOL-100 domain structure) was Test-Retest Reliability. Test re-test stability of the WHOQOL-100 was obtained with a second application (approximately 21 to 35 days later) of the instrument to a subgroup of 52 subjects (controls and patients). Results showed a good test re-test stability, with Pearson s test re-test correlations ranging from 0.67 (Spirituality) to 0.86 (Level of Independence). Discriminant Validity. Discriminant validity of the WHOQOL-100 was assessed by the ability of domains scores to differentiate between patients and the healthy group of respondents. To be acceptable, the domains should score high, indicating a good quality of life when people are well, and low when people are ill. Table 3 presents the results of the discriminant validity analysis. Table 3 A comparison of domains scores from ill and well respondents shows that discriminant validity was statistically significant for all domains, with the exception of 11

12 Domain 6 (Spirituality/Religion/Personal Beliefs). As predicted, the overall healthy group reported higher scores of quality of life than subjects of the clinical group. A significant mean difference also existed for the general facet. Considering the health department (or the nature of the disease), psychiatric patients reported the worst results in quality of life scores, except in Domains 1 (Physical) and 3 (Level of Independence), in which patients from the Rheumatology department reported poorer scores. The results are described in Table 4. Table 4 The highest discriminatory power of the WHOQOL-100 was found both in Physical [F(5, 598)=30, 092, p.001] and Level of Independence [F(5, 598)=78, 899, p.001] domains, where all comparisons with the control group proved to be statistically significant. The Psychological Domain also showed to have good discriminative ability [F(5, 598)=19, 184, p.001], but differences are only significant regarding patients from Psychiatry (p.001), Gynaecology (p.05) and Rheumatology (p.05). The Social Relations Domain [F(5, 598)=17, 781, p.001] also differentiates patients from non-patients; however, the difference is only significant in comparison with psychiatric patients. Regarding the Environment Domain, there are differences between the control group and the patients from Psychiatry, Gynaecology and the Health Centres [F(5, 598)=12, 089, p.001]. Although the Spirituality Domain did not discriminate patients from the general population (cf. Table 3), and the domain score was not significantly different across 12

13 groups of patients, a statistically significant difference was found between the control group and the Psychiatry subgroup [F(5, 598)=2, 327, p.05]. Construct Validity. Table 5 presents the construct validity results. All Pearson correlations between the domains scores of the WHOQOL-100 were statistically significant. The highest correlations were found between the following domains: Physical and Level of Independence (r=0.74), Psychological and Social Relationships (r=0.66), and Social Relationships and Environment (r=0.63). Domain 6 (Spirituality/Religion/Personal Beliefs) showed the lowest correlation coefficients with the remaining domains (ranging from 0.15 to 0.35). Table 5 All domains, with the exception of Spirituality (r=0.25), showed higher and significant correlations with the general facet of quality of life. The correlations ranged from 0.61 (Physical) to 0.69 (Psychological and Level of Independence). Convergent validity. All domains of WHOQOL-100 reported statistically significant correlations (p.001) with both the BDI total score (ranging from to ) and the BSI Global Severity Index (ranging from to -0.69). The correlation goes in the hypothesized direction, i.e. higher values of quality of life are associated with lower results in depression and in psychopathological symptoms. Results also show that both BDI and BSI correlated most highly with the Psychological Domain (correspondingly and -0.69). The global scores of BDI and 13

14 BSI showed the lowest correlations with Domain 6 (Spirituality/Religion/Personal beliefs), respectively, and The PF.25 Political Power. The four selected questions showed a good correlation within the facet in which they are included (r ranging from 0.67 to 0.85), as well as an adequate internal consistency (Cronbach s = 0.78). The PF 25 reported a good discrimination capacity between patients (n=289) and general population (n=315) [t(1, 602)=2, 988, p.01]; with individuals of the general population reporting higher scores than patients. PF 25 also showed a good test-retest reliability (r=0.83; p<.000). DISCUSSION This paper describes the pilot and field studies of the WHOQOL-100 (European Portuguese version). In the development and validation of the WHOQOL-100 for European Portuguese, the qualitative pilot study was a crucial phase, corroborating the multidimensional concept of the Quality of Life definition proposed by the WHO and leading to the construction of a national facet (PF 25. Political Power). This facet proved to have good psychometric properties (internal consistency and test-retest stability), as well as good discriminant validity between normal healthy subjects and patients. Core issues of PF25 appear to reflect people s subjective perception of the efficiency of political decisions that interfere with their own quality of life. The Portuguese facet is part of the national version of the WHOQOL-100 as an isolated facet, obeying to the recommendations of WHOQOL Group of not changing the established structure of the domains, thus permitting a cross-cultural comparison of the data. Finally, we should mention that, considering the several national facets 14

15 emerging in the various centres, which developed vernacular versions of the questionnaire, the necessity to develop a facet to assess political power is a novelty in the already considerable history of the WHOQOL. The authors do not exclude the hypothesis that the emergence of a Political facet in the Portuguese WHOQOL-100 version may be a consequence of the political situation lived in Portugal, namely the fact that the Prime Minister resigned in order to be appointed President of the European Commission and the establishment of a new government, which lasted only three months. This political and consequent economic instability reflected a significant dissatisfaction among the Portuguese population. Although this could be seen as a study limitation, there was a general agreement in the Portuguese team that the political decisions do have a major impact on subjects quality of life and this fact justifies the inclusion of this new facet. Regarding the psychometric properties of the European Portuguese version of WHOQOL-100, the results showed that the instrument performs well. In fact, WHOQOL-100 revealed high values of internal consistency reliability (for all items and across all domains), construct validity and test re-test stability, as well as good discriminant validity. Regarding discriminant validity, Domain 6 (Spirituality/Religion/Personal Beliefs) did not prove to discriminate between healthy controls and subjects from the clinical population. These results were also reported by other WHOQOL centres (Fleck, Louzada et al., 1999; Bonomi, Patrick, Bushnell, & Martin, 2000), and can be the result of factors concerning the fragility of the domain, as it is assessed by fewer questions than other domains. Also, this domain might be less affected by the presence of a health condition. However, the WHOQOL-100 is particularly good at discriminating healthy 15

16 people from people with compromised health status. The best discriminatory power was found in the Independence and Physical domains. Taking into account the origin of the patients comprising the clinical group, we noticed a trend for Psychiatric patients to report lower results in quality of life scores than other patients, except in Domain 1 (Physical) and 3 (Level of Independence). In these domains patients from the Rheumatology department reported the worst results. These results are understandable considering the nature of the pathologies observed in this department and are similar to the results found at other centres (Fleck, Louzada et al., 1999), which used patients with analogous pathologies. These results refer to an initial application of the instrument to a small sample of the Portuguese population. Plans are under way for further testing: regional variations, socio-cultural differences, and particular aspects should be studied in a larger sample that is representative of the Portuguese Population. In summary, we can state that the psychometric properties of the European Portuguese version of the quality of life assessment instrument of the WHO (WHOQOL-100) allow the worthwhile use of this version of the WHOQOL-100 in multiple populations in Portugal, such as psychiatric patients, chronically ill patients, patients with less severe health conditions, and healthy individuals. But the WHOQOL- 100 instrument has other strengths: it was developed and standardised to measure QoL cross-culturally and is now available in approximately 50 languages; therefore, it is also appropriate for use in multinational collaborative research. ACKNOWLEDGEMENTS 16

17 The authors wish to thank the WHOQOL Group, particularly Professors Shekhar Saxena, Somnath Chatterji, Mark Van Ommeren e Debashish Chattopadhyay. A very special thanks to Prof. Marcelo Fleck, co-ordinator of the Brazilian WHOQOL Centre, consultant of the WHOQOL Project of European Portuguese, for all the support given during the various phases of this process. BIBLIOGRAPHIC REFERENCES Beck, A. T., Ward, C., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, Berlim, M. T., Pavanello, D. P., Caldieraro, M. A., & Fleck, M. (2005). Reliability and validity of the WHOQOL BREF in a sample of Brazilian outpatients with major depression. Quality of Life Research, 14, Bonomi, A. E., Patrick, D. L., Bushnell, D. M., & Martin, M. (2000). Validation of the United States version of the World Health Organization Quality of Life (WHOQOL) instrument. Journal of Clinical Epidemiology, 53, Canavarro, M. C. (1999). Inventário de Sintomas Psicopatológicos - BSI. In M. R. Simões, M. Gonçalves & L. Almeida (eds.), Testes e provas psicológicas em Portugal - Vol. 2 (pp ). Braga: APPORT/SHO. Canavarro, M. C., Vaz Serra, A., Pereira, M., Simões, M. R., Quintais, L., Quartilho, M. J., et al. (2006). Desenvolvimento do Instrumento de Avaliação da Qualidade de Vida da Organização Mundial de Saúde (WHOQOL-100) para Português de Portugal. Psiquiatria Clínica, 27(1), Derogatis, L. R. (1993). BSI: Brief Symptom Inventory. Administration, Scoring and Procedures Manual. Minneapolis: National Computers Systems. 17

18 Fleck, M. (2000). O instrumento de avaliação de qualidade de vida da Organização Mundial da Saúde (WHOQOL-100): Características e perspectivas. Ciência & Saúde Colectiva, 5(1), Fleck, M., Leal, O., Louzada, S., Xavier, M., Chachamovich, E., Vieira, G., et al. (1999). Desenvolvimento da versão em português do instrumento de avaliação de qualidade de vida da OMS (WHOQOL-100). Revista Brasileira de Psiquiatria, 21(1), Fleck, M., Louzada, S., Xavier, M., Chachamovich, E., Vieira, G., Santos, L., et al. (1999). Aplicação da versão em português do instrumento de avaliação de qualidade de vida da OMS (WHOQOL-100). Revista de Saúde Pública, 33(2), Fleck, M., Louzada, S., Xavier, M., Chachamovich, E., Vieira, G., Santos, L., et al. (2000). Aplicação da versão em português do instrumento abreviado de avaliação de qualidade de vida WHOQOL-bref. Revista de Saúde Pública, 33(2), Orley, J. (1994). The World Health Organization (WHO) Quality of Life Project. In M. Trimble & W. Dodson (Eds.), Epilepsy and quality of life (pp ). New York: Raven Press. Rijo, D., Canavarro, M. C., Pereira, M., Simões, M. R., Vaz Serra, A., Quartilho, M. J., et al. (2006). Especificidades da avaliação da Qualidade de Vida na população portuguesa: O processo de construção da faceta portuguesa do WHOQOL-100. Psiquiatria Clínica, 27(1), Skevington, S. M. (1999). Measuring Quality of Life in Britain: Introducing the WHOQOL-100. Journal of Psychosomatic Research, 47(5),

19 Skevington, S., Bradshaw, J., & Saxena, S. (1999). Selecting national items for the WHOQOL: conceptual and psychometric considerations. Social Science & Medicine, 48, Skevington, S. M., Lotfy, M., & O Connel, K. A. (2004). The World Health Organization s WHOQOL-BREF quality of life assessment: Psychometric properties and results of the international field trial. A report from the WHOQOL Group. Quality of Life Research, 13, Skevington, S. M., Sartorius, N., Amir, M., & WHOQOL Group. (2004). Developing methods for assessing quality of life in different cultural settings. Social Psychiatry Epidemiology, 39, 1-8. Vaz Serra, A., Canavarro, M. C., Simões, M. R., Pereira, M., Gameiro, S., Quartilho, M. J., et al. (2006a). Estudos psicométricos do instrumento de avaliação da Qualidade de Vida da Organização Mundial de Saúde (WHOQOL-100) para Português de Portugal. Psiquiatria Clínica, 27(1), Vaz Serra, A., Canavarro, M. C., Simões, M. R., Pereira, M., Gameiro, S., Quartilho, M. J., et al. (2006b). Estudos psicométricos do instrumento de avaliação da Qualidade de Vida da Organização Mundial de Saúde (WHOQOL-Bref) para Português de Portugal. Psiquiatria Clínica, 27(1), Vaz Serra, A., & Pio Abreu, J. L. (1973a). Aferição dos quadros clínicos depressivos. I Ensaio de aplicação do Inventário Depressivo de Beck a uma amostra portuguesa de doentes deprimidos. Coimbra Médica, XX, Vaz Serra, A., & Pio Abreu, J. L. (1973b). Aferição dos quadros clínicos depressivos. II Estudo preliminar de novos agrupamentos sintomatológicos para complemento do Inventário Depressivo de Beck. Coimbra Médica, XX,

20 WHOQOL Group. (1994a). Development of the WHOQOL: Rationale and Current Status. International Journal of Mental Health, 23(3), WHOQOL Group. (1994b). The development of the World Health Organization Quality of Life Assessment Instrument (the WHOQOL). In J. Orley & W. Kuyken (eds.), Quality of Life Assessment: International perspectives (pp ). Berlin: Springer-Verlag. WHOQOL Group (1995). The World Health Organization Quality of Life Assessment (WHOQOL): Position paper from the World Health Organization. Social Science & Medicine, 41(10), WHOQOL Group. (1998). The World Health Organization Quality of Life Assessment (WHOQOL): Development and General Psychometric Properties. Social Science & Medicine, 46(12), Wolfensberger, W. (1994). Lets hang up "Quality of Life" as a hopeless term. In D. Goode (ed.), Quality of life for persons with disabilities: International perspectives and issues (pp ). Cambridge: Brookline Books. 20

21 Figure 1 21

22 Figure 2 22

23 Table 1 General characteristics of the sample Control (N=315) Patients (N=289) Total (N=604) n % n % n % Age years > 45 years Gender Male Female Education No education Primary school Middle School Secondary School Higher Education Marital Status Single Married/Co-habiting Separated/Divorced Widower Type of treatment Inpatients Outpatients

24 Table 2 WHOQOL-100: Cronbach alphas of the facets, domains, 100 items and of the 6 specific domains Cronbach Number of Cases Number of Items Facets Domains items D1 (Physical) D2 (Psychological ) D3 (Level of Independence) D4 (Social Relationships) D5 (Environment) D6 (Spirituality) Table 3 WHOQOL-100: Comparison of the scores in the different domains and general facet between patients and controls WHOQoL Domain CONTROLS (n=315) Mean (SD) PATIENTS (n=289) t p Mean (SD) D1 (Physical) (13.47) (16.99) D2 (Psychological) (12.93) (15.40) D3 (Level of Independence) (12.72) (19.93) D4 (Social Relationships) (13.17) (15.12) D5 (Environment) (10.18) (11.62) D6 (Spirituality) (17.30) (18.50) General QoL (14.03) (18.15)

25 Table 4 WHOQOL-100: Comparison of the mean scores in the different domains among patients Health Department WHOQoL Domain Psychiatry (n=59) Gynaecology (n=31) Rheumatology (n=73) Health Centres (n=54) Oncology (n=72) Controls F D1 (Physical) a ** D2 (Psychological) b ** D3 (Level of Independence) a ** D4 (Social Relationships) b ** D5 (Environment) d ** D6 (Spirituality) c * * p.05; ** p.001 a Controls > Psychiatry, Gynaecology, Rheumatology, Health Centres, and Oncology b Psychiatry < Gynaecology, Rheumatology, Health Centres, Oncology, and Controls c Controls > Psychiatry d Controls > Psychiatry, Gynaecology, and Health Centres 25

26 Table 5 WHOQOL-100: Pearson correlations among domains and general facet WHOQoL Domain D1 D2 D3 D4 D5 D6 D1 (Physical) - D2 (Psychological).60 - D3 (Level of Independence) D4 (Social Relationships) D5 (Environment) D6 (Spirituality) General QoL All correlations significant for p