WORLD HEALTH ORGANIZATION
DISABILITY ASSESSMENT SCHEDULE WHODAS II
Phase 2 Field Trials – Health Services Research 12 +24 Interviewer Administered, Days Version February 2000
This instrument was developed by the WHO’s Assessment, Classification and Epidemiology Group within the framework of the WHO/NIH Joint Project on Assessment and Classification of Disablements. The International Task Force members who contributed to the development of this instrument include:
Elizabeth Badley Karen Ritchie Srinivasa Murthy Charles Pull Hans Hoek Durk Wiersma Martin Prince The WHO team:
Canada France India Luxembourg Netherlands Netherlands UK
Somnath Chatterji Patrick Doyle JoAnne Epping-Jordan Matilde Leonardi
Ron Kessler Robert Trotter Michael Von Korff Robert Battjes Bennett Fletcher Bridget Grant Cille Kennedy
Jayne Lux Christopher Nelson Jurgen Rehm Ritu Sadana
USA USA USA NIDA NIDA NIAAA NIMH
Shekhar Saxena T. Bedirhan Üstün
Field Trial Centers:
Thomas Kugener Kruy Kim Hourn Yao Guizhong Jesús Saíz Venos Mavreas Srinivasa Murthy Hemraj Pal Ugo Nocentini Miyako Tazaki Elie Karam Charles Pull
Austria Cambodia China Cuba Greece India, Bangalore India, Delhi Italy Japan Lebanon Luxembourg
Hans Hoek Bisi Odejide José Luis Segura García Radu Vrasti José Luis Vazquez Barquero Adel Chaker Berna Ulug Martin Prince Ron Kessler Katherine McGonagle Michael Von Korff
Netherlands Nigeria Peru Romania Spain Tunisia Turkey UK USA USA USA
The proper use of this instrument requires appropriate training of interviewers including use of the WHO-DAS II Interviewer’s Training Manual and Interview Guide. The computerized version of the interview (I shell) is available for computer assisted interviews or for data entry. Informant (proxy) and self-administered versions of this instrument are available for field testing. Permission to translate this instrument into any language should be obtained from WHO. All translations should be prepared according to the WHO translation guidelines. For additional information, please contact: Dr T. Bedirhan Üstün Group Leader Assessment, Classification and Epidemiology Group World Health Organization CH – 1211 Geneva 27 Switzerland Tel: + + 41 22 791 3609 Fax: + + 41 22 791 4885 Email:
[email protected]
2
SECTION 1. Face Sheet ITEMS F1- F6 ARE TO BE COMPLETED BY INTERVIEWERS PRIOR TO STARTING EACH INTERVIEW F1
RESPONDENT I.D . # CENTRE # - SUBJECT #
F2
INTERVIEWER I.D. # CENTRE # - INTERVIEWER #
F3
ASSESSMENT TIME POINT (1, 2, ETC.)
F4
INTERVIEW DATE
F5
LIVING SITUATION AT TIME OF INTERVIEW (CIRCLE ONLY ONE)
F6
___ ___/___ ___/___ ___ month day year
SAMPLE (CIRCLE ONLY ONE)
Independent in Community
1
Assisted Living
2
Hospitalized
3
General population
1
Drug related problems
2
Alcohol related problems
3
Mental health problems
4
Physical problems
5
Other (specify)
6
__________________________
3
SECTION 2. DEMOGRAPHIC AND BACKGROUND INFORMATION
PREAMBLE This interview has been developed by the World Health Organization to better understand the difficulties people may have due to their health conditions. The information that you provide in this interview is confidential and will be used only for research. FOR RESPONDENTS FROM THE GENERAL POPULATION (NOT THE CLINICAL POPULATION) SAY: Even if you are healthy and have no difficulties, it is necessary that I ask all of the questions for completeness. I will begin with some background questions.
Female Male
1 2
A1
RECORD SEX AS OBSERVED
A2
How old are you now?
___/___ years
A3
How many years in all did you spend studying in school, college or university?
___/___ years
A4
What is your current marital status? (SELECT THE SINGLE BEST OPTION)
4
Never married
1
Currently married
2
Separated
3
Divorced
4
Widowed
5
Cohabiting
6
A5
Which describes your main work status best? (SELECT THE SINGLE BEST OPTION)
Paid work
1
Self employed, such as own your business or farming
2
Non paid work, such as volunteer or charity
3
Student
4
Keeping house/Homemaker
5
Retired
6
Unemployed (health reasons) 7 Unemployed (other reasons)
8
Other (specify)
9
__________________________
5
SECTION 3: PREAMBLE SAY TO RESPONDENT: The interview is about difficulties people have because of health conditions. (HAND FLASHCARD #1 TO RESPONDENT). By health condition I mean diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems and problems with alcohol or drugs. I remind you to keep all of your health problems in mind as you answer the questions. When I ask you about difficulties in doing an activity think about (POINT TO FLASHCARD #1). • • • •
Increased effort Discomfort or pain Slowness Changes in the way you do the activity
(POINT TO FLASHCARD #1). When answering, I’d like you to think back over the last 30 days. I also would like you to answer these questions thinking about how much difficulty you have, on average over the past 30 days, while doing the activity as you usually do it.
(HAND FLASHCARD #2 TO RESPONDENT). Use this scale when responding. (READ SCALE ALOUD): None, mild, moderate, severe, extreme or cannot do.
(FLASHCARDS #1 AND #2 SHOULD REMAIN VISIBLE TO THE RESPONDENT THROUGHOUT THE INTERVIEW. )
6
SECTION 4. CORE QUESTIONS SHOW FLASHCARD #2 to participant In the last 30 days how much difficulty did you have in:
S1
S2
S3
S4
S5
None
Mild
Moderate
Severe
Extreme /Cannot Do
Standing for long periods such as 30 minutes?
1
2
3
4
5
Taking care of your household responsibilities?
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Learning a new task, for example, learning how to get to a new place?
How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
How much have you been emotionally affected by your health problems?
IF ANY OF S1-S5 ARE ENDORSED (RATED GREATER THAN NONE), CONTINUE WITH S6-S12 OTHERWISE, THIS IS THE END OF THE INTERVIEW. This concludes our interview, thank you for participating.
7
In the last 30 days how much difficulty did you have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
S6
Concentrating on doing something for ten minutes?
1
2
3
4
5
S7
Walking a long distance such as a kilometre [or equivalent]?
1
2
3
4
5
S8
Washing your whole body?
1
2
3
4
5
S9
Getting dressed?
1
2
3
4
5
S10
Dealing with people you do not know?
1
2
3
4
5
S11
Maintaining a friendship?
1
2
3
4
5
S12
Your day to day work?
1
2
3
4
5
H3
Overall, in the past 30 days, how many days were these difficulties present?
RECORD NUMBER OF DAYS ___/___
CONTINUE BY ADMINISTERING THE SPECIFIED DOMAINS AS FOLLOWS: IF QUESTION IS ENDORSED (CODED 2-5)
GO TO
DOMAIN NUMBER
S3 or S6
1 on page 7
S1 or S7
2 on page 8
S8 or S9
3 on page 9
S10 or S11
4 on page 10
S2 or S12
5 on pages 11-12
S4 or S5
6 on page 13 –14 8
DOMAIN 1 Understanding and Communicating
Now I am going to ask some questions about understanding and communicating.
show flashcards #1 AND #2 for responses greater than NONE (1), ASK: how many days was this difficulty present? RECORD NUMBER OF DAYS (0 - 30) In the last 30 days, how much difficulty did you have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Number Days
D1.2
Remembering to do important things?
1
2
3
4
5
_______ D1.2d
D1.3
Analysing and finding solutions to problems in day to day life?
1
2
3
4
5
_______ D1.3d
D1.5
Generally understanding what people say?
1
2
3
4
5
_______ D1.5d
D1.6
Starting and maintaining a conversation?
1
2
3
4
5
_______ D1.6d
Probe: IF ANY OF D1.1 – D1.6 ARE RATED GREATER THAN NONE (1), ASK:
P1.1
How much did these difficulties interfere with your life?
9
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
DOMAIN 2 Getting Around
I am now going to ask you about difficulties in getting around.
SHOW FLASHCARDS #1 AND #2 for responses greater than NONE (1), ASK: how many days was this difficulty present? RECORD NUMBER OF DAYS (0-30) In the last 30 days, how much difficulty did you have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Number Days
D2.2
Standing up from sitting down?
1
2
3
4
5
_______ D2.2d
D2.3
Moving around inside your home?
1
2
3
4
5
_______ D2.3d
D2.4
Getting out of your home?
1
2
3
4
5
_______ D2.4d
Probe: IF ANY OF D2.1 –D2.5 ARE RATED GREATER THAN NONE (1), ASK:
P2.1
How much did these difficulties interfere with your life?
10
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
DOMAIN 3 Self Care
I am now going to ask you about difficulties in taking care of yourself.
SHOW FLASHCARDS #1 AND #2 for responses greater than NONE (1), SHOW FLASHCARD #3 ASK: how many days was this difficulty present? RECORD NUMBER OF DAYS (0-30) In the last 30 days, how much difficulty did you have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
D3.3
Eating?
1
2
3
4
5
D3.4
Staying by yourself for a few days?
1
2
3
4
5
Number Days
_______ D3.3d
_______ D3.4d
Probe: IF ANY OF D3.1 – D3.4 ARE RATED GREATER THAN NONE (1), ASK:
P3.1
How much did these difficulties interfere with your life?
11
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
DOMAIN 4 Getting along with people
I am now going to ask you about difficulties in getting along with people. Please remember that I am asking only about difficulties that are due to health problems. By this I mean diseases or illnesses, injuries, mental or emotional problems and problems with alcohol or drugs.
SHOW FLASHCARDS #1 AND #2 for responses greater than NONE (1), SHOW FLASHCARD #3 ASK: how many days was this difficulty present? RECORD NUMBER OF DAYS (0-30) In the last 30 days, how much difficulty did you have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Number Days
D4.3
Getting along with people who are close to you?
1
2
3
4
5
_______ D4.3d
D4.4
Making new friends?
1
2
3
4
5
_______ D4.4d
D4.5
Sexual activities?
1
2
3
4
5
_______ D4.5d
Probe: IF ANY OF D4.1 – D4.5 ARE RATED GREATER THAN NONE (1), ASK:
P4.1
How much did these difficulties interfere with your life?
12
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
DOMAIN 5 Life Activities • Household Activities The following questions are about activities involved in maintaining your household, and in caring for the people with whom you live or those close to you. These activities include cooking, cleaning, shopping, caring for others and caring for your belongings.
D5.1
How many hours do you spend in these activities in a typical week?
RECORD NUMBER OF HOURS __/__
SHOW FLASHCARDS #1 AND #2 for responses greater than NONE (1), ASK: how many days was this difficulty present? RECORD NUMBER OF DAYS (0-30) Because of your health condition, in the last 30 days, how much difficulty did you have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Number Days
D5.3
Doing your most important household tasks well?
1
2
3
4
5
_______ D5.3d
D5.4
Getting all the household work done that you needed to do?
1
2
3
4
5
_______ D5.4d
D5.5
Getting your household work done as quickly as needed?
1
2
3
4
5
_______ D5.5d
IF ANY OF D5.2 – D5.5 ARE RATED GREATER THAN NONE (1), ASK:
P5.1
D5.6
How much did these difficulties interfere with your life?
In the last 30 days, on how many days did you reduce or completely miss household work because of your health condition?
None
Mild
1
2
Moderate
3
Severe
Extreme /Cannot Do
4
5
RECORD NUMBER OF DAYS
13
__/__
IF RESPONDENT WORKS (PAID, NON-PAID, SELF EMPLOYED) OR GOES TO SCHOOL, COMPLETE QUESTIONS D5.7-D5.13. OTHERWISE, SKIP TO D6.1 ON THE NEXT PAGE
Now I will ask some questions about your work or school activities. D5.7
How many hours do you spend in work (which includes school) in a typical week?
RECORD NUMBER OF HOURS __ /__
SHOW FLASHCARDS #1 AND #2 for responses greater than NONE (1), ASK: how many days was this difficulty present? RECORD NUMBER OF DAYS (0-30) Because of your health condition, in the last 30 days how much difficulty did you have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Number Days
D5.9
Doing your most important work tasks well?
1
2
3
4
5
_______ D5.9d
D5.10
Getting all the work done that you need to do?
1
2
3
4
5
_______ D5.10d
D5.11
Getting your work done as quickly as needed?
1
2
3
4
5
_______ D5.11d
D5.12
Have you had to work at a lower level because of a health condition?
No Yes
1 2
D5.13
Did you earn less money as the result of a health condition?
No Yes
1 2
IF ANY OF D5.8 – D5.11 ARE RATED GREATER THAN NONE (1), ASK:
P5.2
D5.14
How much did these difficulties interfere with your life?
In the last 30 days, on how many days did you miss work for half a day or more because of your health condition?
14
None
Mild
1
2
Moderate
3
Severe
Extreme /Cannot Do
4
5
RECORD NUMBER OF DAYS __/__
DOMAIN 6 Participation in Society Now, I am going to ask you about your participation in society and the impact of your health problems on you and your family. Some of these questions may involve problems that go beyond the last 30 days, however in answering, please focus on the last 30 days. Again, I remind you to answer these questions while thinking about health problems: physical, mental or emotional, alcohol or drug related.
SHOW FLASHCARDS #1 AND #2 NOTE THAT THE NUMBER OF DAYS FOR EACH QUESTION IN THIS DOMAIN IS NOT REQUESTED. In the last 30 days:
Severe
Extreme /Cannot Do
3
4
5
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
None
Mild
How much of a problem did you have because of barriers or hindrances in the world around you?
1
2
How much of a problem did you have living with dignity because of the attitudes and actions of others?
1
D6.4
How much time did you spend on your health condition, or its consequences?
D6.6
How much has your health been a drain on the financial resources of you or your family?
D6.2
D6.3
D6.7
How much of a problem did your family have because of your health problems?
D6.8
How much of a problem did you have in doing things by yourself for relaxation or pleasure?
15
Moderate
Probe: IF ANY OF D6.1 – D6.8 ARE RATED GREATER THAN NONE (1), ASK:
P6.1
How much did these problems interfere with your life?
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
P6.2
In the last 30 days, for how many days did you have these difficulties?
RECORD NUMBER OF DAYS __/__
H3
Overall, in the past 30 days, how many days did you experience any of the difficulties that we have discussed during this interview?
RECORD NUMBER OF DAYS
This concludes our interview, thank you for participating.
16
___/___
Health Conditions: • Diseases, illnesses or other health problems • Injuries • Mental or emotional problems • Problems with alcohol • Problems with drugs
Having difficulty with an activity means: • • • •
Increased effort Discomfort or pain Slowness Changes in the way you do the activity
Think about the past 30 days only
Flashcard #1
17
Flashcard #2
1 None
2
3
Mild
Moderate
4 Severe
5 Extreme / Cannot Do
2
World Health Organization Disability Assessment Schedule II
For Office Use Only: __ __ __ - __ __ __ - ___ Center# Subject # - Time #
Phase 2 Field Trials – Health Services Research 12-Item Self-Administered Version
__ __/ __ __ / __ __ Day / Month / Year Pop:
q q q q q q
H1
How do you rate your overall health in the past 30 days?
Very good
Good
Dwelling: 1 Independent 1 Assisted 1 Hospitalized
Gen Drg Alc Mnh Phys Other
Moderate
Bad
Very Bad
This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the last 30 days and answer these questions thinking about how much difficulty you had doing the following activities. For each question, please circle only one response. In the last 30 days, how much difficulty did you have in:
S1
Standing for long periods such as 30 minutes?
None
Mild
Moderate
Severe
Extreme /Cannot Do
S2
Taking care of your household responsibilities?
None
Mild
Moderate
Severe
Extreme /Cannot Do
S3
Learning a new task, for example, learning how to get to a new place?
None
Mild
Moderate
Severe
Extreme /Cannot Do
S4
How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
None
Mild
Moderate
Severe
Extreme /Cannot Do
None
Mild
Moderate
Severe
Extreme /Cannot Do
S5
How much have you been emotionally affected by your health problems?
Please continue to the next page …
1
In the last 30 days, how much difficulty did you have in:
S6
Concentrating on doing something for ten minutes?
None
Mild
Moderate
Severe
Extreme /Cannot Do
S7
Walking a long distance such as a kilometre [or equivalent]?
None
Mild
Moderate
Severe
Extreme /Cannot Do
S8
Washing your whole body?
None
Mild
Moderate
Severe
Extreme /Cannot Do
S9
Getting dressed?
None
Mild
Moderate
Severe
Extreme /Cannot Do
S10
Dealing with people you do not know?
None
Mild
Moderate
Severe
Extreme /Cannot Do
S11
Maintaining a friendship?
None
Mild
Moderate
Severe
Extreme /Cannot Do
S12
Your day to day work?
None
Mild
Moderate
Severe
Extreme /Cannot Do
H2
Overall, how much did these difficulties interfere with your life?
Moderately
Severely
Extremely
H3
Overall, in the past 30 days, how many days were these difficulties present?
RECORD NUMBER OF DAYS
In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?
RECORD NUMBER OF DAYS
In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?
RECORD NUMBER OF DAYS
H4
H5
Not at all
Mildly
___/___
___/___
___/___
This completes the questionnaire. Thank you.
2
WORLD HEALTH ORGANIZATION
DISABILITY ASSESSMENT SCHEDULE WHODAS II Phase 2 Field Trials – Health Services Research 12-Item Interviewer Administered Version February 2000
This instrument was developed by the WHO’s Assessment, Classification and Epidemiology Group within the framework of the WHO/NIH Joint Project on Assessment and Classification of Disablements. The International Task Force members who contributed to the development of this instrument include:
Elizabeth Badley Karen Ritchie Srinivasa Murthy Charles Pull Hans Hoek Durk Wiersma Martin Prince The WHO team:
Canada France India Luxembourg Netherlands Netherlands UK
Somnath Chatterji Patrick Doyle JoAnne Epping-Jordan Matilde Leonardi
Ron Kessler Robert Trotter Michael Von Korff Robert Battjes Bennett Fletcher Bridget Grant Cille Kennedy
Jayne Lux Christopher Nelson Jurgen Rehm Ritu Sadana
USA USA USA NIDA NIDA NIAAA NIMH
Shekhar Saxena T. Bedirhan Üstün
Field Trial Centers:
Thomas Kugener Kruy Kim Hourn Yao Guizhong Jesús Saíz Venos Mavreas Srinivasa Murthy Hemraj Pal Ugo Nocentini Miyako Tazaki Elie Karam Charles Pull
Austria Cambodia China Cuba Greece India, Bangalore India, Delhi Italy Japan Lebanon Luxembourg
Hans Hoek Bisi Odejide José Luis Segura García Radu Vrasti José Luis Vazquez Barquero Adel Chaker Berna Ulug Martin Prince Ron Kessler Katherine McGonagle Michael Von Korff
Netherlands Nigeria Peru Romania Spain Tunisia Turkey UK USA USA USA
The proper use of this instrument requires appropriate training of interviewers including use of the WHO-DAS II Interviewer’s Training Manual and Interview Guide. The computerized version of the interview (I shell) is available for computer assisted interviews or for data entry. Informant (proxy) and self-administered versions of this instrument are available for field testing. Permission to translate this instrument into any language should be obtained from WHO. All translations should be prepared according to the WHO translation guidelines. For additional information, please contact: Dr T. Bedirhan Üstün Group Leader Assessment, Classification and Epidemiology Group World Health Organization CH – 1211 Geneva 27 Switzerland Tel: + + 41 22 791 3609 Fax: + + 41 22 791 4885 Email:
[email protected]
2
SECTION 1. Face Sheet ITEMS F1- F6 ARE TO BE COMPLETED BY INTERVIEWERS PRIOR TO STARTING EACH INTERVIEW F1
RESPONDENT I.D . # CENTRE # - SUBJECT #
F2
INTERVIEWER I.D. # CENTRE # - INTERVIEWER #
F3
ASSESSMENT TIME POINT (1, 2, ETC.)
F4
INTERVIEW DATE
F5
LIVING SITUATION AT TIME OF INTERVIEW (CIRCLE ONLY ONE)
F6
___ ___/___ ___/___ ___ month day year
SAMPLE (CIRCLE ONLY ONE)
Independent in Community
1
Assisted Living
2
Hospitalized
3
General population
1
Drug related problems
2
Alcohol related problems
3
Mental health problems
4
Physical problems
5
Other (specify)
6
__________________________
3
SECTION 2. DEMOGRAPHIC AND BACKGROUND INFORMATION
PREAMBLE This interview has been developed by the World Health Organization to better understand the difficulties people may have due to their health conditions. The information that you provide in this interview is confidential and will be used only for research. FOR RESPONDENTS FROM THE GENERAL POPULATION (NOT THE CLINICAL POPULATION) SAY: Even if you are healthy and have no difficulties, it is necessary that I ask all of the questions for completeness. I will begin with some background questions.
Female Male
1 2
A1
RECORD SEX AS OBSERVED
A2
How old are you now?
___/___ years
A3
How many years in all did you spend studying in school, college or university?
___/___ years
A4
What is your current marital status? (SELECT THE SINGLE BEST OPTION)
4
Never married
1
Currently married
2
Separated
3
Divorced
4
Widowed
5
Cohabiting
6
A5
Which describes your main work status best? (SELECT THE SINGLE BEST OPTION)
Paid work
1
Self employed, such as own your business or farming
2
Non paid work, such as volunteer or charity
3
Student
4
Keeping house/Homemaker
5
Retired
6
Unemployed (health reasons) 7 Unemployed (other reasons)
8
Other (specify)
9
__________________________
5
SECTION 3: PREAMBLE SAY TO RESPONDENT: The interview is about difficulties people have because of health conditions. (HAND FLASHCARD #1 TO RESPONDENT). By health condition I mean diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems and problems with alcohol or drugs. I remind you to keep all of your health problems in mind as you answer the questions. When I ask you about difficulties in doing an activity think about (POINT TO FLASHCARD #1). • • • •
Increased effort Discomfort or pain Slowness Changes in the way you do the activity
(POINT TO FLASHCARD #1). When answering, I’d like you to think back over the last 30 days. I also would like you to answer these questions thinking about how much difficulty you have, on average over the past 30 days, while doing the activity as you usually do it.
(HAND FLASHCARD #2 TO RESPONDENT). Use this scale when responding. (READ SCALE ALOUD): None, mild, moderate, severe, extreme or cannot do.
(FLASHCARDS #1 AND #2 SHOULD REMAIN VISIBLE TO THE RESPONDENT THROUGHOUT THE INTERVIEW. )
6
SECTION 4. CORE QUESTIONS H1
How do you rate your overall health in the past 30 days?
Very good
Good
Moderate
Bad
Very Bad
Read choices to respondent.
SHOW FLASHCARD #2 to participant In the last 30 days how much difficulty did you have in:
S1
S2
S3
S4
S5
Severe
Extreme /Cannot Do
3
4
5
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
None
Mild
Standing for long periods such as 30 minutes?
1
2
Taking care of your household responsibilities?
1
Learning a new task, for example, learning how to get to a new place?
How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
How much have you been emotionally affected by your health problems?
Continue to next page…
7
Moderate
In the last 30 days how much difficulty did you have in:
H2
H3
None
Mild
Moderate
Severe
Extreme /Cannot Do
S6
Concentrating on doing something for ten minutes?
1
2
3
4
5
S7
Walking a long distance such as a kilometre [or equivalent]?
1
2
3
4
5
S8
Washing your whole body?
1
2
3
4
5
S9
Getting dressed?
1
2
3
4
5
S10
Dealing with people you do not know?
1
2
3
4
5
S11
Maintaining a friendship?
1
2
3
4
5
S12
Your day to day work?
1
2
3
4
5
Overall, how much did these difficulties interfere with your life? Read choices to respondent. Overall, in the past 30 days, how many days were these difficulties present?
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
RECORD NUMBER OF DAYS ___/___
H4
In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?
RECORD NUMBER OF DAYS __/__
H5
In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?
RECORD NUMBER OF DAYS __/__
This concludes our interview, thank you for participating. 8
Health Conditions: • Diseases, illnesses or other health problems • Injuries • Mental or emotional problems • Problems with alcohol • Problems with drugs
Having difficulty with an activity means: • • • •
Increased effort Discomfort or pain Slowness Changes in the way you do the activity
Think about the past 30 days only
Flashcard #1
9
Flashcard #2
1 None
2
3
Mild
Moderate
4 Severe
5 Extreme/ Cannot Do
2
World Health Organization Disability Assessment Schedule II
For Office Use Only: __ __ __ - __ __ __ - ___ Center# Subject # Time #
Phase 2 Field Trials – Health Services Research 36-Item Self-Administered Version
__ __/ __ __ / __ __ Day / Month / Year Pop:
q q q q q q H1
How do you rate your overall health in the past 30 days?
Very good
Good
Moderate
Gen Drg Alc Mnh Phys Other
Bad
Dwelling: 1 Independent 1 Assisted 1 Hospitalized
Very Bad
This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the last 30 days and answer these questions thinking about how much difficulty you had doing the following activities. For each question, please circle only one response. In the last 30 days, how much difficulty did you have in: Understanding and communicating Extreme/ Cannot Do Extreme/ Cannot Do
D1.1
Concentrating on doing something for ten minutes?
None
Mild
Moderate
Severe
D1.2
Remembering to do important things?
None
Mild
Moderate
Severe
D1.3
Analyzing and finding solutions to problems in day to day life?
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D1.4
Learning a new task, for example, learning how to get to a new place?
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D1.5
Generally understanding what people say?
None
Mild
Moderate
Severe
D1.6
Starting and maintaining a conversation?
None
Mild
Moderate
Severe
Extreme/ Cannot Do Extreme/ Cannot Do
Getting around D2.1
Standing for long periods such as 30 minutes?
None
Mild
Moderate
Severe
D2.2
Standing up from sitting down?
None
Mild
Moderate
Severe
D2.3
Moving around inside your home?
None
Mild
Moderate
D2.4
Getting out of your home?
None
Mild
Moderate
Severe
D2.5
Walking a long distance such as a kilometre (or equivalent)?
None
Mild
Moderate
Severe
Severe
Please continue to the next page … 1
Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do
In the last 30 days, how much difficulty did you have in: Self Care D3.1
Washing your whole body?
None
D3.2
Getting dressed?
None
D3.3
Eating?
None
D3.4
Staying by yourself for a few days?
None
Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe
Moderate
Severe
Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do
Getting along with people Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do
D4.1
Dealing with people you do not know?
None
Mild
D4.2
Maintaining a friendship?
None
Mild
Moderate
Severe
D4.3
Getting along with people who are close to you?
None
Mild
Moderate
Severe
D4.4
Making new friends?
None
Mild
Moderate
Severe
D4.5
Sexual activities?
None
Mild
Moderate
Severe
D5.1 Taking care of your household responsibilities?
None
Mild
Moderate
Severe
D5.2 Doing most important household tasks well?
None
Mild
Moderate
Severe
D5.3 Getting all the household work done that you needed to
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
Life activities
do?
D5.4 Getting your household work done as quickly as needed?
Extreme/ Cannot Do Extreme/ Cannot Do
IF YOU WORK (PAID, NON-PAID, SELF EMPLOYED) OR GO TO SCHOOL, COMPLETE QUESTIONS D5.5-D5.8 BELOW. OTHERWISE, SKIP TO D6.1 AT THE TOP OF THE NEXT PAGE. In the last 30 days, how much difficulty did you have in:
D5.5 Your day to day work/school?
None
Mild
Moderate
Severe
D5.6 Doing your most important work/school tasks well?
None
Mild
Moderate
Severe
D5.7 Getting all the work done that you need to do?
None
Mild
Moderate
Severe
D5.8 Getting your work done as quickly as needed?
None
Mild
Moderate
Severe
Please continue to the next page …
2
Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do
In the last 30 days: Participation in Society
D6.1
How much of a problem did you have in joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D6.2
How much of a problem did you have because of barriers or hindrances in the world around you?
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D6.3
How much of a problem did you have living with dignity because of the attitudes and actions of others
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D6.4
How much time did you spend on your health condition, or its consequences
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D6.5
How much have you been emotionally affected by your health condition
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D6.6
How much has your health been a drain on the financial resources of you or your family
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D6.7
How much of a problem did your family have because of your health problems
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D6.8
How much of a problem did you have in doing things by yourself for relaxation or pleasure
None
Mild
Moderate
Severe
Extreme/ Cannot Do
H2
Overall, how much did these difficulties interfere with your life?
H3
Overall, in the past 30 days, how many days were these difficulties present?
RECORD NUMBER OF DAYS
In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?
RECORD NUMBER OF DAYS
In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?
RECORD NUMBER OF DAYS
H4
H5
Not at all
Mildly
Moderately
Severely
___/___
___/___
This completes the questionnaire. Thank you.
3
___/___
Extremely
WORLD HEALTH ORGANIZATION
DISABILITY ASSESSMENT SCHEDULE WHODAS II
Phase 2 Field Trials – Health Services Research 36-Item Interviewer Administered, Days Version February 2000
This instrument was developed by the WHO’s Assessment, Classification and Epidemiology Group within the framework of the WHO/NIH Joint Project on Assessment and Classification of Disablements. The International Task Force members who contributed to the development of this instrument include:
Elizabeth Badley Karen Ritchie Srinivasa Murthy Charles Pull Hans Hoek Durk Wiersma Martin Prince The WHO team:
Canada France India Luxembourg Netherlands Netherlands UK
Somnath Chatterji Patrick Doyle JoAnne Epping-Jordan Matilde Leonardi
Ron Kessler Robert Trotter Michael Von Korff Robert Battjes Bennett Fletcher Bridget Grant Cille Kennedy
Jayne Lux Christopher Nelson Jurgen Rehm Ritu Sadana
USA USA USA NIDA NIDA NIAAA NIMH
Shekhar Saxena T. Bedirhan Üstün
Field Trial Centers:
Thomas Kugener Kruy Kim Hourn Yao Guizhong Jesús Saíz Venos Mavreas Srinivasa Murthy Hemraj Pal Ugo Nocentini Miyako Tazaki Elie Karam Charles Pull
Austria Cambodia China Cuba Greece India, Bangalore India, Delhi Italy Japan Lebanon Luxembourg
Hans Hoek Bisi Odejide José Luis Segura García Radu Vrasti José Luis Vazquez Barquero Adel Chaker Berna Ulug Martin Prince Ron Kessler Katherine McGonagle Michael Von Korff
Netherlands Nigeria Peru Romania Spain Tunisia Turkey UK USA USA USA
The proper use of this instrument requires appropriate training of interviewers including use of the WHO-DAS II Interviewer’s Training Manual and Interview Guide. The computerized version of the interview (I shell) is available for computer assisted interviews or for data entry. Informant (proxy) and self-administered versions of this instrument are available for field testing. Permission to translate this instrument into any language should be obtained from WHO. All translations should be prepared according to the WHO translation guidelines. For additional information, please contact: Dr T. Bedirhan Üstün Group Leader Assessment, Classification and Epidemiology Group World Health Organization CH – 1211 Geneva 27 Switzerland Tel: + + 41 22 791 3609 Fax: + + 41 22 791 4885 Email:
[email protected]
2
SECTION 1. Face Sheet ITEMS F1- F6 ARE TO BE COMPLETED BY INTERVIEWERS PRIOR TO STARTING EACH INTERVIEW F1
RESPONDENT I.D . # CENTRE # - SUBJECT #
F2
INTERVIEWER I.D. # CENTRE # - INTERVIEWER #
F3
ASSESSMENT TIME POINT (1, 2, ETC.)
F4
INTERVIEW DATE
F5
LIVING SITUATION AT TIME OF INTERVIEW (CIRCLE ONLY ONE)
F6
___ ___/___ ___/___ ___ month day year
SAMPLE (CIRCLE ONLY ONE)
Independent in Community
1
Assisted Living
2
Hospitalized
3
General population
1
Drug related problems
2
Alcohol related problems
3
Mental health problems
4
Physical problems
5
Other (specify)
6
__________________________
3
SECTION 2. DEMOGRAPHIC AND BACKGROUND INFORMATION
PREAMBLE This interview has been developed by the World Health Organization to better understand the difficulties people may have due to their health conditions. The information that you provide in this interview is confidential and will be used only for research. FOR RESPONDENTS FROM THE GENERAL POPULATION (NOT THE CLINICAL POPULATION) SAY: Even if you are healthy and have no difficulties, it is necessary that I ask all of the questions for completeness. I will begin with some background questions.
A1
RECORD SEX AS OBSERVED
Female Male
A2
How old are you now?
___/___ years
A3
How many years in all did you spend studying in school, college or university?
___/___ years
A4
What is your current marital status? (SELECT THE SINGLE BEST OPTION)
4
1 2
Never married
1
Currently married
2
Separated
3
Divorced
4
Widowed
5
Cohabiting
6
A5
Which describes your main work status best? (SELECT THE SINGLE BEST OPTION)
Paid work
1
Self employed, such as own your business or farming
2
Non paid work, such as volunteer or charity
3
Student
4
Keeping house/Homemaker
5
Retired
6
Unemployed (health reasons) 7 Unemployed (other reasons)
8
Other (specify)
9
__________________________
5
SECTION 3: PREAMBLE SAY TO RESPONDENT: The interview is about difficulties people have because of health conditions. (HAND FLASHCARD #1 TO RESPONDENT). By health condition I mean diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems and problems with alcohol or drugs. I remind you to keep all of your health problems in mind as you answer the questions. When I ask you about difficulties in doing an activity think about (POINT TO FLASHCARD #1). • • • •
Increased effort Discomfort or pain Slowness Changes in the way you do the activity
(POINT TO FLASHCARD #1). When answering, I’d like you to think back over the last 30 days. I also would like you to answer these questions thinking about how much difficulty you have, on average over the past 30 days, while doing the activity as you usually do it.
(HAND FLASHCARD #2 TO RESPONDENT). Use this scale when responding. (READ SCALE ALOUD): None, mild, moderate, severe, extreme or cannot do.
(FLASHCARDS #1 AND #2 SHOULD REMAIN VISIBLE TO THE RESPONDENT THROUGHOUT THE INTERVIEW. )
6
SECTION 4. DOMAIN REVIEWS DOMAIN 1 Understanding and Communicating
I am going to ask some questions about understanding and communicating.
SHOW FLASHCARDS #1 AND #2 FOR RESPONSES GREATER THAN NONE (1), ASK: How many days was this difficulty present? RECORD NUMBER OF DAYS (0 -30) In the last 30 days, how much difficulty did you have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Number Days
D1.1
Concentrating on doing something for ten minutes?
1
2
3
4
5
_______ D1.1d
D1.2
Remembering to do important things?
1
2
3
4
5
_______ D1.2d
D1.3
Analysing and finding solutions to problems in day to day life?
1
2
3
4
5
_______ D1.3d
D1.4
Learning a new task, for example, learning how to get to a new place?
1
2
3
4
5
D1.5
Generally understanding what people say?
1
2
3
4
5
_______ D1.5d
D1.6
Starting and maintaining a conversation?
1
2
3
4
5
_______ D1.6d
_______ D1.4d
Probe: IF ANY OF D1.1 – D1.6 ARE RATED GREATER THAN NONE (1), ASK:
P1.1
How much did these difficulties interfere with your life?
7
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
DOMAIN 2 Getting Around
I am now going to ask you about difficulties in getting around.
SHOW FLASHCARDS #1 AND #2 FOR RESPONSES GREATER THAN NONE (1), ASK: How many days was this difficulty present? RECORD NUMBER OF DAYS (0-30) In the last 30 days, how much difficulty did you have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Number Days
D2.1
Standing for long periods such as 30 minutes?
1
2
3
4
5
_______ D2.1d
D2.2
Standing up from sitting down?
1
2
3
4
5
_______ D2.2d
D2.3
Moving around inside your home?
1
2
3
4
5
_______ D2.3d
D2.4
Getting out of your home?
1
2
3
4
5
_______ D2.4d
D2.5
Walking a long distance such as a kilometre [or equivalent]?
1
2
3
4
5
_______ D2.5d
Probe: IF ANY OF D2.1 –D2.5 ARE RATED GREATER THAN NONE (1), ASK:
P2.1
How much did these difficulties interfere with your life?
8
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
DOMAIN 3 Self Care
I am now going to ask you about difficulties in taking care of yourself.
SHOW FLASHCARDS #1 AND #2 FOR RESPONSES GREATER THAN NONE (1), ASK: How many days was this difficulty present? RECORD NUMBER OF DAYS (0-30) In the last 30 days, how much difficulty did you have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Number Days
D3.1
Washing your whole body?
1
2
3
4
5
_______ D3.1d
D3.2
Getting dressed?
1
2
3
4
5
_______ D3.2d
D3.3
Eating?
1
2
3
4
5
_______ D3.3d
D3.4
Staying by yourself for a few days?
1
2
3
4
5
_______ D3.4d
Probe: IF ANY OF D3.1 – D3.4 ARE RATED GREATER THAN NONE (1), ASK:
P3.1
How much did these difficulties interfere with your life?
9
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
DOMAIN 4 Getting along with people
I am now going to ask you about difficulties in getting along with people. Please remember that I am asking only about difficulties that are due to health problems. By this I mean diseases or illnesses, injuries, mental or emotional problems and problems with alcohol or drugs.
SHOW FLASHCARDS #1 AND #2 FOR RESPONSES GREATER THAN NONE (1), ASK: How many days was this difficulty present? RECORD NUMBER OF DAYS (0-30) In the last 30 days, how much difficulty did you have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Number Days
D4.1
Dealing with people you do not know?
1
2
3
4
5
_______ D4.1d
D4.2
Maintaining a friendship?
1
2
3
4
5
_______ D4.2d
D4.3
Getting along with people who are close to you?
1
2
3
4
5
_______ D4.3d
D4.4
Making new friends?
1
2
3
4
5
_______ D4.4d
D4.5
Sexual activities?
1
2
3
4
5
_______ D4.5d
Probe: IF ANY OF D4.1 – D4.5 ARE RATED GREATER THAN NONE (1), ASK:
P4.1
How much did these difficulties interfere with your life?
10
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
DOMAIN 5 Life Activities • Household Activities The following questions are about activities involved in maintaining your household, and in caring for the people with whom you live or those close to you. These activities include cooking, cleaning, shopping, caring for others and caring for your belongings.
D5.1
How many hours do you spend in these activities in a typical week?
RECORD NUMBER OF HOURS __/__
SHOW FLASHCARDS #1 AND #2 FOR RESPONSES GREATER THAN NONE (1), ASK: How many days was this difficulty present? RECORD NUMBER OF DAYS (0-30) Because of your health condition, in the last 30 days, how much difficulty did you have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Number Days
D5.2
Taking care of your household responsibilities?
1
2
3
4
5
_______ D5.2d
D5.3
Doing your most important household tasks well?
1
2
3
4
5
_______ D5.3d
D5.4
Getting all the household work done that you needed to do?
1
2
3
4
5
_______ D5.4d
D5.5
Getting your household work done as quickly as needed?
1
2
3
4
5
_______ D5.5d
IF ANY OF D5.2 – D5.5 ARE RATED GREATER THAN NONE (1), ASK:
P5.1
D5.6
How much did these difficulties interfere with your life?
In the last 30 days, on how many days did you reduce or completely miss household work because of your health condition?
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
RECORD NUMBER OF DAYS
11
__/__
IF RESPONDENT WORKS (PAID, NON-PAID, SELF EMPLOYED) OR GOES TO SCHOOL, COMPLETE QUESTIONS D5.7-D5.13. OTHERWISE, SKIP TO D6.1 ON THE NEXT PAGE
Now I will ask some questions about your work or school. D5.7
How many hours do you spend in work (which includes school) in a typical work week?
RECORD NUMBER OF HOURS __ /__
SHOW FLASHCARDS #1 AND #2 FOR RESPONSES GREATER THAN NONE (1), ASK: How many days was this difficulty present? RECORD NUMBER OF DAYS (0-30) Because of your health condition, in the last 30 days how much difficulty did you have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Number Days
D5.8
Your day to day work?
1
2
3
4
5
_______ D5.8d
D5.9
Doing your most important work tasks well?
1
2
3
4
5
_______ D5.9d
D5.10
Getting all the work done that you need to do?
1
2
3
4
5
_______ D5.10d
D5.11
Getting your work done as quickly as needed?
1
2
3
4
5
_______ D5.11d
D5.12
Have you had to work at a lower level because of a health condition?
No Yes
1 2
D5.13
Did you earn less money as the result of a health condition?
No Yes
1 2
IF ANY OF D5.8 – D5.11 ARE RATED GREATER THAN NONE (1), ASK:
P5.2
D5.14
How much did these difficulties interfere with your life?
In the last 30 days, on how many days did you miss work for half a day or more because of your health condition?
12
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
RECORD NUMBER OF DAYS __/__
DOMAIN 6 Participation in Society Now, I am going to ask you about your participation in society and the impact of your health problems on you and your family. Some of these questions may involve problems that go beyond the last 30 days, however in answering, please focus on the last 30 days. Again, I remind you to answer these questions while thinking about health problems: physical, mental or emotional, alcohol or drug related.
SHOW FLASHCARDS #1 AND #2 NOTE THAT THE NUMBER OF DAYS FOR EACH QUESTION IN THIS DOMAIN IS NOT REQUESTED. None
Mild
Moderate
Severe
Extreme /Cannot Do
How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
1
2
3
4
5
How much of a problem did you have because of barriers or hindrances in the world around you?
1
2
3
4
5
How much of a problem did you have living with dignity because of the attitudes and actions of others?
1
2
3
4
5
D6.4
How much time did you spend on your health condition, or its consequences?
1
2
3
4
5
D6.5
How much have you been emotionally affected by your health condition?
1
2
3
4
5
D6.6
How much has your health been a drain on the financial resources of you or your family?
1
2
3
4
5
In the last 30 days: D6.1
D6.2
D6.3
13
In the last 30 days: D6.7
How much of a problem did your family have because of your health problems?
D6.8
How much of a problem did you have in doing things by yourself for relaxation or pleasure?
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
1
2
3
4
5
Probe: IF ANY OF D6.1 – D6.8 ARE RATED GREATER THAN NONE (1), ASK:
P6.1
How much did these problems interfere with your life?
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
P6.2
In the last 30 days, for how many days did you have these difficulties?
RECORD NUMBER OF DAYS __/__
H3
Overall, in the past 30 days, how many days did you experience any of the difficulties that we have discussed during this interview?
RECORD NUMBER OF DAYS
This concludes our interview, thank you for participating.
14
___/___
Health Conditions: • Diseases, illnesses or other health problems • Injuries • Mental or emotional problems • Problems with alcohol • Problems with drugs
Having difficulty with an activity means: • • • •
Increased effort Discomfort or pain Slowness Changes in the way you do the activity
Think about the past 30 days only
Flashcard #1 15
Flashcard #2
1 None
2
3
Mild
Moderate
4 Severe
5 Extreme / Cannot Do
World Health Organization Disability Assessment Schedule II
For Office Use Only: __ __ __ - __ __ __ - ___ Center# Subject # - Time #
Phase 2 Field Trials – Health Services Research 6-Item Proxy Informant Version
__ __/ __ __ / __ __ Day / Month / Year Pop:
q q q q q q
Gen Drg Alc Mnh Phys Other
Dwelling: 1 Independent 1 Assisted 1 Hospitalized
This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the last 30 days and, to the best of your knowledge, answer these questions thinking about how much difficulty your relative* had while doing the following activities. For each question, please circle only one response. (* This term is defined broadly for the purpose of this questionnaire, and can include friends or acquaintances.) H1
How do you rate your relative’s overall health in the past 30 days?
Very good
Good
Moderate
Bad
Very Bad
In the last 30 days, how much difficulty did your relative have in… CS1
CS2
CS3
CS4
CS5
Understanding and communicating. • Concentrating or remembering • Finding solutions to problems • Learning something new • Generally understanding and communicating with people Getting around. • Standing for long periods • Standing up from sitting down • Moving around inside the home • Getting out of the home • Difficulty with walking a long distance such as a kilometer Self care. • Washing his/her whole body • Getting dressed • Eating • Staying alone for a few days Getting along with people. • Dealing with people who are strangers • Maintaining a friendship • Getting along with people who are close • Controlling feelings Household activities or work or school activities. • Getting these activities done • Doing these activities well • Doing them as quickly as needed
Please continue to the next page …
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
In the last 30 days, how much difficulty did your relative have in… CS6
Participation in society. • The world and other people creating problems • Discrimination • Problems in living with dignity • Problems joining in community activities
H2
Overall, how much did all of these difficulties interfere with your relative’s life?
H3
Overall, in the past 30 days, how many days were these difficulties present?
None
Mild
Not at all
Moderate
Mildly
Moderately
Severe
Severely
RECORD NUMBER OF DAYS ___/___
H4
H5
H6
In the past 30 days, for how many days was your relative totally unable to carry out his/her usual activities or work because of any health condition?
RECORD NUMBER OF DAYS
In the past 30 days, not counting the days that your relative was totally unable, for how many days did your relative cut back or reduce his/her usual activities or work because of any health condition?
RECORD NUMBER OF DAYS
In the past 30 days, how many days have you seen or spoken with your relative?
RECORD NUMBER OF DAYS
___/___
___/___
___/___
H7
I am the _________ (choose one) of this person.
1 = husband or wife 2 = parent 3 = son or daughter 4 = brother or sister 5 = other relative 6 = friend 7 = professional carer 8 = other (specify) _____________
This completes the questionnaire. Thank you.
Extreme/ Cannot Do
Extremely
World Health Organization Disability Assessment Schedule II
For Office Use Only: __ __ __ - __ __ __ - ___ Center# Subject # - Time #
Phase 2 Field Trials – Health Services Research 6-Item Clinician Proxy Version
__ __/ __ __ / __ __ Day / Month / Year Pop:
q q q q q q
Gen Drg Alc Mnh Phys Other
Dwelling: 1 Independent 1 Assisted 1 Hospitalized
This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the last 30 days and, to the best of your knowledge, answer these questions thinking about how much difficulty your patient had while doing the following activities. For each question, please circle only one response. H1
How do you rate your patient’s overall health in the past 30 days?
Very good
Good
Moderate
Bad
Very Bad
In the last 30 days, how much difficulty did your patient have in… CS1
CS2
CS3
CS4
CS5
Understanding and communicating. • Concentrating or remembering • Finding solutions to problems • Learning something new • Generally understanding and communicating with people Getting around. • Standing for long periods • Standing up from sitting down • Moving around inside the home • Getting out of the home • Difficulty with walking a long distance such as a kilometer Self care. • Washing his/her whole body • Getting dressed • Eating • Staying alone for a few days Getting along with people. • Dealing with people who are strangers • Maintaining a friendship • Getting along with people who are close • Controlling feelings Household activities or work or school activities. • Getting these activities done • Doing these activities well • Doing them as quickly as needed
Please continue to the next page …
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
In the last 30 days, how much difficulty did your patient have in… CS6
Participation in society. • The world and other people creating problems • Discrimination • Problems in living with dignity • Problems joining in community activities
H2
Overall, how much did all of these difficulties interfere with your patient’s life?
H3
Overall, in the past 30 days, how many days were these difficulties present?
None
Not at all
Mild
Mildly
Moderate
Moderately
Severe
Severely
RECORD NUMBER OF DAYS ___/___
H4
H5
H6
In the past 30 days, for how many days was your patient totally unable to carry out his/her usual activities or work because of any health condition?
RECORD NUMBER OF DAYS
In the past 30 days, not counting the days that your patient was totally unable, for how many days did your patient cut back or reduce his/her usual activities or work because of any health condition?
RECORD NUMBER OF DAYS
In the past 30 days, how many days have you seen or spoken with your patient?
RECORD NUMBER OF DAYS
___/___
___/___
___/___
This completes the questionnaire. Thank you.
Extreme/ Cannot Do
Extremely
World Health Organization Disability Assessment Schedule II
For Office Use Only: __ __ __ - __ __ __ - ___ Center# Subject # - Time #
Phase 2 Field Trials – Health Services Research 36-Item Proxy Informant Version
__ __/ __ __ / __ __ Day / Month / Year Pop:
q q q q q q
Dwelling: 1 Independent 1 Assisted 1 Hospitalized
Gen Drg Alc Mnh Phys Other
This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the last 30 days and, to the best of your knowledge, answer these questions thinking about how much difficulty your relative* had while doing the following activities. For each question, please circle only one response. (* This term is defined broadly for the purpose of this questionnaire, and can include friends or acquaintances.) H1
How do you rate your relative’s overall health in the past 30 days?
Very good
Good
Moderate
Bad
Very Bad
In the last 30 days, how much difficulty did your relative have in… Understanding and communicating Extreme/ Cannot Do Extreme/ Cannot Do
D1.1
Concentrating on doing something for ten minutes?
None
Mild
Moderate
Severe
D1.2
Remembering to do important things?
None
Mild
Moderate
Severe
D1.3
Analyzing and finding solutions to problems in day to day life?
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D1.4
Learning a new task, for example, learning how to get to a new place?
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D1.5
Generally understanding what people say?
None
Mild
Moderate
Severe
D1.6
Starting and maintaining a conversation?
None
Mild
Moderate
Severe
Please continue to the next page …
1
Extreme/ Cannot Do Extreme/ Cannot Do
In the last 30 days, how much difficulty did your relative have in: Getting around D2.1
Standing for long periods such as 30 minutes?
None
Mild
Moderate
Severe
D2.2
Standing up from sitting down?
None
Mild
Moderate
Severe
D2.3
Moving around inside the home?
None
Mild
Moderate
Severe
D2.4
Getting out of the home?
None
Mild
Moderate
Severe
D2.5
Walking a long distance such as a kilometre (or equivalent)?
None
Mild
Moderate
Severe
Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do
Self Care D3.1
Washing his/her whole body?
None
Mild
Moderate
Severe
D3.2
Getting dressed?
None
Mild
Moderate
Severe
D3.3
Eating?
None
Mild
Moderate
Severe
D3.4
Staying by himself/herself for a few days?
None
Mild
Moderate
Severe
Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do
Getting along with people D4.1
Dealing with people he/she does not know?
None
Mild
Moderate
Severe
D4.2
Maintaining a friendship?
None
Mild
Moderate
Severe
D4.3
Getting along with people who are close to him/her?
None
Mild
Moderate
Severe
D4.4
Making new friends?
None
Mild
Moderate
Severe
D4.5
Sexual activities?
None
Mild
Moderate
Severe
D5.1 Taking care of his/her household responsibilities?
None
Mild
Moderate
Severe
D5.2 Doing his/her most important household tasks well?
None
Mild
Moderate
Severe
D5.3 Getting all the household work done that is needed?
None
Mild
Moderate
Severe
D5.4 Getting the household work done as quickly as needed?
None
Mild
Moderate
Severe
Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do
Life activities
Please continue to the next page …
2
Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do
IF YOUR RELATIVE WORKS (PAID, NON-PAID, SELF EMPLOYED) OR GOES TO SCHOOL, COMPLETE QUESTIONS D5.5-D5.8 BELOW. OTHERWISE, SKIP TO D6.1 NEAR THE MIDDLE OF THE PAGE. In the last 30 days, how much difficulty did your relative have in: D5.5
His/her day to day work/school?
Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do
None
Mild
Moderate
Severe
D5.6 Doing his/her most important work/school tasks well?
None
Mild
Moderate
Severe
D5.7 Getting all the work done that is needed?
None
Mild
Moderate
Severe
D5.8 Getting the work done as quickly as needed?
None
Mild
Moderate
Severe
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
Participation in society In the last 30 days:
D6.1 How much of a problem did your relative have in joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
D6.2 How much of a problem did your relative have because of barriers or hindrances in the world around him/her?
D6.3 How much of a problem did your relative have living with dignity because of the attitudes and actions of others?
D6.4 How much time did your relative spend on his/her health condition, or its consequences?
D6.5 How much has your relative been emotionally affected by his/her health condition?
D6.6 How much has his/her health been a drain on his/her financial resources or on the financial resources of other relatives?
D6.7 How much of a problem did you or the rest of his/her family have because of his/her health problems?
D6.8 How much of a problem did your relative have in doing things by him/herself for relaxation or pleasure?
Please continue to the next page …
3
H2
Overall, how much did all of these difficulties interfere with your relative’s life?
H3
Overall, in the past 30 days, how many days were these difficulties present?
Not at all
Mildly
Moderately
Severely
RECORD NUMBER OF DAYS ___/___
H4
H5
H6
In the past 30 days, for how many days was your relative totally unable to carry out his/her usual activities or work because of any health condition?
RECORD NUMBER OF DAYS
In the past 30 days, not counting the days that your relative was totally unable, for how many days did your relative cut back or reduce his/her usual activities or work because of any health condition?
RECORD NUMBER OF DAYS
In the past 30 days, how many days have you seen or spoken with your relative?
RECORD NUMBER OF DAYS
___/___
___/___
___/___
H7
I am the ___________ (choose one) of this person.
1 = husband or wife 2 = parent 3 = son or daughter 4 = brother or sister 5 = other relative 6 = friend 7 = professional carer 8 = other (specify) _____________
This completes the questionnaire. Thank you.
4
Extremely
World Health Organization Disability Assessment Schedule II
For Office Use Only: __ __ __ - __ __ __ - ___ Center# Subject # Time #
Phase 2 Field Trials – Health Services Research 36-Item Self-Administered Version
__ __/ __ __ / __ __ Day / Month / Year Pop:
q q q q q q H1
How do you rate your overall health in the past 30 days?
Very good
Good
Moderate
Gen Drg Alc Mnh Phys Other
Bad
Dwelling: 1 Independent 1 Assisted 1 Hospitalized
Very Bad
This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the last 30 days and answer these questions thinking about how much difficulty you had doing the following activities. For each question, please circle only one response. In the last 30 days, how much difficulty did you have in: Understanding and communicating Extreme/ Cannot Do Extreme/ Cannot Do
D1.1
Concentrating on doing something for ten minutes?
None
Mild
Moderate
Severe
D1.2
Remembering to do important things?
None
Mild
Moderate
Severe
D1.3
Analyzing and finding solutions to problems in day to day life?
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D1.4
Learning a new task, for example, learning how to get to a new place?
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D1.5
Generally understanding what people say?
None
Mild
Moderate
Severe
D1.6
Starting and maintaining a conversation?
None
Mild
Moderate
Severe
Extreme/ Cannot Do Extreme/ Cannot Do
Getting around D2.1
Standing for long periods such as 30 minutes?
None
Mild
Moderate
Severe
D2.2
Standing up from sitting down?
None
Mild
Moderate
Severe
D2.3
Moving around inside your home?
None
Mild
Moderate
D2.4
Getting out of your home?
None
Mild
Moderate
Severe
D2.5
Walking a long distance such as a kilometre (or equivalent)?
None
Mild
Moderate
Severe
Severe
Please continue to the next page … 1
Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do
In the last 30 days, how much difficulty did you have in: Self Care D3.1
Washing your whole body?
None
D3.2
Getting dressed?
None
D3.3
Eating?
None
D3.4
Staying by yourself for a few days?
None
Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe
Moderate
Severe
Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do
Getting along with people Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do
D4.1
Dealing with people you do not know?
None
Mild
D4.2
Maintaining a friendship?
None
Mild
Moderate
Severe
D4.3
Getting along with people who are close to you?
None
Mild
Moderate
Severe
D4.4
Making new friends?
None
Mild
Moderate
Severe
D4.5
Sexual activities?
None
Mild
Moderate
Severe
D5.1 Taking care of your household responsibilities?
None
Mild
Moderate
Severe
D5.2 Doing most important household tasks well?
None
Mild
Moderate
Severe
D5.3 Getting all the household work done that you needed to
None
Mild
Moderate
Severe
Extreme/ Cannot Do
None
Mild
Moderate
Severe
Extreme/ Cannot Do
Life activities
do?
D5.4 Getting your household work done as quickly as needed?
Extreme/ Cannot Do Extreme/ Cannot Do
IF YOU WORK (PAID, NON-PAID, SELF EMPLOYED) OR GO TO SCHOOL, COMPLETE QUESTIONS D5.5-D5.8 BELOW. OTHERWISE, SKIP TO D6.1 AT THE TOP OF THE NEXT PAGE. In the last 30 days, how much difficulty did you have in:
D5.5 Your day to day work/school?
None
Mild
Moderate
Severe
D5.6 Doing your most important work/school tasks well?
None
Mild
Moderate
Severe
D5.7 Getting all the work done that you need to do?
None
Mild
Moderate
Severe
D5.8 Getting your work done as quickly as needed?
None
Mild
Moderate
Severe
Please continue to the next page …
2
Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do Extreme/ Cannot Do
In the last 30 days: Participation in Society
D6.1
How much of a problem did you have in joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D6.2
How much of a problem did you have because of barriers or hindrances in the world around you?
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D6.3
How much of a problem did you have living with dignity because of the attitudes and actions of others
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D6.4
How much time did you spend on your health condition, or its consequences
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D6.5
How much have you been emotionally affected by your health condition
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D6.6
How much has your health been a drain on the financial resources of you or your family
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D6.7
How much of a problem did your family have because of your health problems
None
Mild
Moderate
Severe
Extreme/ Cannot Do
D6.8
How much of a problem did you have in doing things by yourself for relaxation or pleasure
None
Mild
Moderate
Severe
Extreme/ Cannot Do
H2
Overall, how much did these difficulties interfere with your life?
H3
Overall, in the past 30 days, how many days were these difficulties present?
RECORD NUMBER OF DAYS
In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?
RECORD NUMBER OF DAYS
In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?
RECORD NUMBER OF DAYS
H4
H5
Not at all
Mildly
Moderately
Severely
___/___
___/___
This completes the questionnaire. Thank you.
3
___/___
Extremely
WORLD HEALTH ORGANIZATION
DISABILITY ASSESSMENT SCHEDULE WHODAS II
Phase 2 Field Trials – Health Services Research 36-Item Interviewer Administered, Proxy Informant Version February 2000
This instrument was developed by the WHO’s Assessment, Classification and Epidemiology Group within the framework of the WHO/NIH Joint Project on Assessment and Classification of Disablements. The International Task Force members who contributed to the development of this instrument include:
Elizabeth Badley Karen Ritchie Srinivasa Murthy Charles Pull Hans Hoek Durk Wiersma Martin Prince The WHO team:
Canada France India Luxembourg Netherlands Netherlands UK
Somnath Chatterji Patrick Doyle JoAnne Epping-Jordan Matilde Leonardi
Ron Kessler Robert Trotter Michael Von Korff Robert Battjes Bennett Fletcher Bridget Grant Cille Kennedy
Jayne Lux Christopher Nelson Jurgen Rehm Ritu Sadana
USA USA USA NIDA NIDA NIAAA NIMH
Shekhar Saxena T. Bedirhan Üstün
Field Trial Centers:
Thomas Kugener Kruy Kim Hourn Yao Guizhong Jesús Saíz Venos Mavreas Srinivasa Murthy Hemraj Pal Ugo Nocentini Miyako Tazaki Elie Karam Charles Pull
Austria Cambodia China Cuba Greece India, Bangalore India, Delhi Italy Japan Lebanon Luxembourg
Hans Hoek Bisi Odejide José Luis Segura García Radu Vrasti José Luis Vazquez Barquero Adel Chaker Berna Ulug Martin Prince Ron Kessler Katherine McGonagle Michael Von Korff
Netherlands Nigeria Peru Romania Spain Tunisia Turkey UK USA USA USA
The proper use of this instrument requires appropriate training of interviewers including use of the WHO-DAS II Interviewer’s Training Manual and Interview Guide. The computerized version of the interview (I shell) is available for computer assisted interviews or for data entry. Informant (proxy) and self-administered versions of this instrument are available for field testing. Permission to translate this instrument into any language should be obtained from WHO. All translations should be prepared according to the WHO translation guidelines. For additional information, please contact: Dr T. Bedirhan Üstün Group Leader Assessment, Classification and Epidemiology Group World Health Organization CH – 1211 Geneva 27 Switzerland Tel: + + 41 22 791 3609 Fax: + + 41 22 791 4885 Email:
[email protected]
2
SECTION 1. Face Sheet ITEMS F1- F7 ARE TO BE COMPLETED BY INTERVIEWERS PRIOR TO STARTING EACH INTERVIEW F1
RESPONDENT I.D . # CENTRE # - SUBJECT #
F2
INTERVIEWER I.D. # CENTRE # - INTERVIEWER #
F3
ASSESSMENT TIME POINT (1, 2, ETC.)
F4
INTERVIEW DATE
F5
LIVING SITUATION AT TIME OF INTERVIEW (CIRCLE ONLY ONE)
F6
___ ___/___ ___/___ ___ month day year
SAMPLE (CIRCLE ONLY ONE)
Independent in Community
1
Assisted Living
2
Hospitalized
3
General population
1
Drug related problems
2
Alcohol related problems
3
Mental health problems
4
Physical problems
5
Other (specify)
6
__________________________
3
F7
PERSON COMPLETNG THIS INTERVIEW IS ___________ OF PRIMARY RESPONDENT
Husband or wife
1
Parent
2
Son or daughter
3
Brother or sister
4
Other relative
5
Friend
6
Professional Carer
7
Other (specify)
8
__________________________
4
SECTION 2. DEMOGRAPHIC AND BACKGROUND INFORMATION
PREAMBLE This interview has been developed by the World Health Organization to better understand the difficulties people may have due to their health conditions. The information that you provide in this interview is confidential and will be used only for research. To the best of your knowledge, please answer these questions thinking about how much difficulty (insert name of primary respondent) had while doing the following activities as (he/she) usually does them. FOR RESPONDENTS FROM THE GENERAL POPULATION (NOT THE CLINICAL POPULATION) SAY: Even if (insert name of primary respondent) is healthy and has no difficulties, it is necessary that I ask all of the questions for completeness. First, I will begin with some background questions about you. QUESTIONS A1 TO A5 REFER TO THE PERSON BEING CURRENTLY INTERVIEWED , NOT TO THE PRIMARY (PATIENT) REPSONDENT.
A1
RECORD SEX AS OBSERVED
Female Male
A2
How old are you now?
___/___ years
A3
How many years in all did you spend studying in school, college or university?
___/___ years
A4
What is your current marital status? (SELECT THE SINGLE BEST OPTION)
5
1 2
Never married
1
Currently married
2
Separated
3
Divorced
4
Widowed
5
Cohabiting
6
A5
Which describes your main work status best? (SELECT THE SINGLE BEST OPTION)
Paid work
1
Self employed, such as own your business or farming
2
Non paid work, such as volunteer or charity
3
Student
4
Keeping house/Homemaker
5
Retired
6
Unemployed (health reasons) 7 Unemployed (other reasons)
8
Other (specify)
9
__________________________
6
SECTION 3: PREAMBLE SAY TO RESPONDENT: The interview is about difficulties people have because of health conditions. (HAND FLASHCARD #1 TO RESPONDENT). By health condition I mean diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems and problems with alcohol or drugs. I remind you to keep all of (insert name of primary respondent) health problems in mind as you answer the questions. When I ask you about difficulties in doing an activity think about (POINT TO FLASHCARD #1). • • • •
Increased effort Discomfort or pain Slowness Changes in the way one does the activity
(POINT TO FLASHCARD #1). When answering, I’d like you to think back over the last 30 days. I also would like you to answer these questions thinking about how much difficulty (insert name of primary respondent) had, on average over the past 30 days, while doing the activity as [he/she] usually does it.
(HAND FLASHCARD #2 TO RESPONDENT). Use this scale when responding. (READ SCALE ALOUD): None, mild, moderate, severe, extreme or cannot do.
(FLASHCARDS #1 AND #2 SHOULD REMAIN VISIBLE TO THE RESPONDENT THROUGHOUT THE INTERVIEW. CARD #3 IS TO BE USED WHEN THE RESPONDENT PROVIDES THE NUMBER OF DAYS DIFFICULTY WAS EXPERIENCED).
7
SECTION 4. DOMAIN REVIEWS DOMAIN 1 Understanding and Communicating
I am going to ask some questions about understanding and communicating.
SHOW FLASHCARDS #1 AND #2 FOR RESPONSES GREATER THAN NONE (1), SHOW FLASHCARD #3 ASK: How many days was this difficulty present? RECORD CODES FOR DAYS (A-E) In the last 30 days, how much difficulty did (insert name of primary respondent) have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Days Code
D1.1
Concentrating on doing something for ten minutes?
1
2
3
4
5
_______ D1.1d
D1.2
Remembering to do important Things?
1
2
3
4
5
_______ D1.2d
D1.3
Analysing and finding solutions to problems in day to day life?
1
2
3
4
5
_______ D1.3d
D1.4
Learning a new task, for example, learning how to get to a new place?
1
2
3
4
5
D1.5
Generally understanding what people say?
1
2
3
4
5
_______ D1.5d
D1.6
Starting and maintaining a conversation?
1
2
3
4
5
_______ D1.6d
_______ D1.4d
Probe: IF ANY OF D1.1 – D1.6 ARE RATED GREATER THAN NONE (1), ASK:
P1.1
How much did these difficulties interfere with [his/her] life?
8
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
DOMAIN 2 Getting Around
I am now going to ask you about difficulties in getting around.
SHOW FLASHCARDS #1 AND #2 FOR RESPONSES GREATER THAN NONE (1), SHOW FLASHCARD #3 ASK: How many days was this difficulty present? RECORD CODES FOR DAYS (A-E) In the last 30 days, how much difficulty did (insert name of primary respondent) have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Days Code
D2.1
Standing for long periods such as 30 minutes?
1
2
3
4
5
_______ D2.1d
D2.2
Standing up from sitting down?
1
2
3
4
5
_______ D2.2d
D2.3
Moving around inside the home?
1
2
3
4
5
_______ D2.3d
D2.4
Getting out of the home?
1
2
3
4
5
_______ D2.4d
D2.5
Walking a long distance such as a kilometre [or equivalent]?
1
2
3
4
5
_______ D2.5d
Probe: IF ANY OF D2.1 –D2.5 ARE RATED GREATER THAN NONE (1), ASK:
P2.1
How much did these difficulties interfere with [his/her] life?
9
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
DOMAIN 3 Self Care
I am now going to ask you about difficulties in taking care of oneself.
SHOW FLASHCARDS #1 AND #2 FOR RESPONSES GREATER THAN NONE (1), SHOW FLASHCARD #3 ASK: How many days was this difficulty present? RECORD CODES FOR DAYS (A-E) In the last 30 days, how much difficulty did (insert name of primary respondent) have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Days Code
D3.1
Washing [his/her] whole body?
1
2
3
4
5
_______ D3.1d
D3.2
Getting dressed?
1
2
3
4
5
_______ D3.2d
D3.3
Eating?
1
2
3
4
5
_______ D3.3d
D3.4
Staying by [himself/herself] for a few days?
1
2
3
4
5
_______ D3.4d
Probe: IF ANY OF D3.1 – D3.4 ARE RATED GREATER THAN NONE (1), ASK:
P3.1
How much did these difficulties interfere with [his/her] life?
10
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
DOMAIN 4 Getting along with people
I am now going to ask you about difficulties in getting along with people. Please remember that I am asking only about difficulties that are due to health problems. By this I mean diseases or illnesses, injuries, mental or emotional problems and problems with alcohol or drugs.
SHOW FLASHCARDS #1 AND #2 FOR RESPONSES GREATER THAN NONE (1), SHOW FLASHCARD #3 ASK: How many days was this difficulty present? RECORD CODES FOR DAYS (A-E) In the last 30 days, how much difficulty did (insert name of primary respondent) have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Dealing with people [he/she] does not know?
1
2
3
4
5
D4.2
Maintaining a friendship?
1
2
3
4
5
_______ D4.2d
D4.3
Getting along with people who are close to [him/her]?
1
2
3
4
5
_______ D4.3d
D4.4
Making new friends?
1
2
3
4
5
_______ D4.4d
D4.5
Sexual activities?
1
2
3
4
5
_______ D4.5d
D4.1
Days Code
_______ D4.1d
Probe: IF ANY OF D4.1 – D4.5 ARE RATED GREATER THAN NONE (1), ASK:
P4.1
How much did these difficulties interfere with [his/her] life?
11
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
DOMAIN 5 Life Activities • Household Activities The following questions are about activities involved in maintaining a household, and in caring for the people with whom (insert name of primary respondent) lives or those close to [him/her]. These activities include cooking, cleaning, shopping, caring for others and caring for [his/her] belongings. D5.1
How many hours does [he/she] spend in these activities in a typical week?
RECORD NUMBER OF HOURS __/__
SHOW FLASHCARDS #1 AND #2 FOR RESPONSES GREATER THAN NONE (1), SHOW FLASHCARD #3 ASK: How many days was this difficulty present? RECORD CODES FOR DAYS (A-E) Because of [his/her] health condition, in the last 30 days, how much difficulty did (insert name of primary respondent) have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Days Code
D5.2
Taking care of [his/her] household responsibilities?
1
2
3
4
5
_______ D5.2d
D5.3
Doing [his/her] most important household tasks well?
1
2
3
4
5
_______ D5.3d
D5.4
Getting all the household work done that [he/she] needed to do?
1
2
3
4
5
_______ D5.4d
D5.5
Getting [his/her] household work done as quickly as needed?
1
2
3
4
5
_______ D5.5d
IF ANY OF D5.2 – D5.5 ARE RATED GREATER THAN NONE (1), ASK:
P5.1
D5.6
How much did these difficulties interfere with [his/her] life?
In the last 30 days, on how many days did [he/she] reduce or completely miss household work because of [his/her] health condition?
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
RECORD NUMBER OF DAYS
12
__/__
IF THE PRIMARY RESPONDENT WORKS (PAID, NON-PAID, SELF EMPLOYED) OR GOES TO SCHOOL, COMPLETE QUESTIONS D5.7-D5.13. OTHERWISE, SKIP TO D6.1 ON THE NEXT PAGE
Now I will ask some questions about (insert name of primary respondent) work or school. D5.7
How many hours does [he/she] spend in work (which includes school) in a typical work week?
RECORD NUMBER OF HOURS __ /__
SHOW FLASHCARDS #1 AND #2 FOR RESPONSES GREATER THAN NONE (1), SHOW FLASHCARD #3 ASK: How many days was this difficulty present? RECORD CODES FOR DAYS (A-E) Because of [his/her] health condition, in the last 30 days how much difficulty did (insert name of primary respondent) have in: None
Mild
Moderate
Severe
Extreme /Cannot Do
Days Code
D5.8
[His/Her] day to day work?
1
2
3
4
5
_______ D5.8d
D5.9
Doing [his/her] most important work tasks well?
1
2
3
4
5
_______ D5.9d
D5.10
Getting all the work done that [he/she] needs to do?
1
2
3
4
5
_______ D5.10d
D5.11
Getting [his/her] work done as quickly as needed?
1
2
3
4
5
_______ D5.11d
D5.12
Has (insert name of primary respondent) had to work at a lower level because of a health condition?
No Yes
1 2
D5.13
Did (insert name of primary respondent) earn less money as the result of a health condition?
No Yes
1 2
IF ANY OF D5.8 – D5.11 ARE RATED GREATER THAN NONE (1), ASK:
P5.2
D5.14
How much did these difficulties interfere with [his/her] life?
In the last 30 days, on how many days did [he/she] miss work for half a day or more because of [his/her] health condition? 13
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
RECORD NUMBER OF DAYS __/__
DOMAIN 6 Participation in Society Now, I am going to ask you about (insert name of primary respondent) participation in society and the impact of [his/her] health problems on [his/her] family. Some of these questions may involve problems that go beyond the last 30 days, however in answering, please focus on the last 30 days. Again, I remind you to answer these questions while thinking about health problems: physical, mental or emotional, alcohol or drug related.
SHOW FLASHCARDS #1 AND #2 NOTE THAT THE NUMBER OF DAYS FOR EACH QUESTION IN THIS DOMAIN IS NOT REQUESTED. None
Mild
Moderate
Severe
Extreme /Cannot Do
How much of a problem did [he/she] have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
1
2
3
4
5
How much of a problem did [he/she] have because of barriers or hindrances in the world around [hom/her]?
1
2
3
4
5
How much of a problem did [he/she] have living with dignity because of the attitudes and actions of others?
1
2
3
4
5
How much time did [he/she] spend on [his/her] health condition, or its consequences?
1
2
3
4
5
How much has [he/she] been emotionally affected by [his/her] health condition?
1
2
3
4
5
How much has [his/her] health been a drain on the financial resources for [him/her] or [his/her] family?
1
2
3
4
5
In the last 30 days: D6.1
D6.2
D6.3
D6.4
D6.5
D6.6
14
In the last 30 days: D6.7
How much of a problem did [his/her] family have because of [his/her] health problems?
D6.8
How much of a problem did [he/she] have in doing things by [himself/herself] for relaxation or pleasure?
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
1
2
3
4
5
Probe: IF ANY OF D6.1 – D6.8 ARE RATED GREATER THAN NONE (1), ASK:
P6.1
How much did these problems interfere with [his/her] life?
None
Mild
Moderate
Severe
Extreme /Cannot Do
1
2
3
4
5
P6.2
In the last 30 days, for how many days did [he/she] have these difficulties?
RECORD NUMBER OF DAYS __/__
H3
Overall, in the past 30 days, how many days did [he/she] experience any of the difficulties that we have discussed during this interview?
RECORD NUMBER OF DAYS
H6
In the past 30 days, how many days have you seen or spoken with (insert name of primary respondent)?
___/___
RECORD NUMBER OF DAYS ___/___
This concludes our interview, thank you for participating.
15
Health Conditions: • Diseases, illnesses or other health problems • Injuries • Mental or emotional problems • Problems with alcohol • Problems with drugs
Having difficulty with an activity means: • • • •
Increased effort Discomfort or pain Slowness Changes in the way one does the activity
Think about the past 30 days only
Flashcard #1 16
Flashcard #2
1 None
2
3
Mild
Moderate
4 Severe
5 Extreme / Cannot Do
Code
A
One day
B
Up to one week
=
2 to 7 days
C
Up to two weeks
=
8 to 14 days
D
More than two weeks
=
15 to 29 days
E
All days
=
30 days
Flashcard #3
