Abstract

The WHODAS 2.0 (World Health Organization Disability Assessment Schedule) is an instrument developed by the WHO (World Health Organization) for functioning and disability assessment based on the biopsychosocial framework, fully supported by the theoretical-conceptual framework of the ICF (International Classification of Functioning, Disability and Health). To validate the Brazilian version of the WHODAS 2.0 for individuals with HIV/AIDS. 100 individuals with diagnosis of HIV/AIDS participated in the study. Two assessment instruments were used: the 36-item version of WHODAS 2.0 and the WHOQOL-HIV-BREF (World Health Organization Quality of Life assessment in persons infected with HIV, shorter version). The psychometric properties tested were internal consistency and criterion validity. Internal consistency was adequate for all domains, with the exception of Life Activities (α = 0.69) and Self-care (α = 0.32). Criterion validity was adequate, with moderate correlations between the WHODAS 2.0 and the WHOQOL-HIV-BREF domains. The results indicated the WHODAS 2.0 instrument as a valid tool for assessing functioning of individuals with HIV/AIDS. The use of data from the Self-care domain should be carefully considered.

Key words
Validation Studies; Disability Evaluation; Acquired Immunodeficiency Syndrome

Introduction

The assessment of disability provides a detailed picture of the impact of health conditions on individuals’ daily life¹1 Silva C, Coleta I, Silva AG, Amaro A, Alvarelhão J, Queirós A, Rocha N. Adaptation and validation of WHODAS 2.0 in patients with musculoskeletal pain. Rev Saude Publica 2013; 47(4):752-758.. This is particularly relevant, as various existing chronic conditions have different impacts on functioning, therefore requiring a more detailed investigation to assess how chronic diseases are affecting people’s activities of daily living²2 Moraes SA, Lopes DA, Freitas ICM. Avaliação do efeito independente de doenças crônicas, fatores sociodemográficos e comportamentais sobre a incapacidade funcional em idosos residentes em Ribeirão Preto, SP, 2007 - Projeto EPIDCV. Rev Bras Epidemiol 2015; 18(4):757-770..

The International Classification of Functioning, Disability and Health (ICF), which follows the biopsychosocial model proposed by the World Health Organization (WHO), defines disability as an umbrella term covering impairments, activity limitations and participation restrictions. This model indicates the negative aspects of the interaction between individuals (with a health condition) and their contextual factors (environmental and personal factors)³3 Organização Mundial da Saúde (OMS). Como usar a CIF: Um manual prático para o uso da Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF). Versão preliminar para discussão. Genebra: OMS; 2013..

Grounded in the theoretical-conceptual framework of the ICF, the WHO developed the World Health Organization Disability Assessment Schedule (WHODAS 2.0): an easy-to-apply instrument which provides a standardized method for measuring health and disability across cultures, and assesses perceived disability associated with health status within 30 days prior to its implementation⁴4 Castro SS, Leite CF. Translation and cross-cultural adaptation of the World Health Organization Disability Assessment Schedule - WHODAS 2.0. Fisioter Pesqui 2017; 24(4):385-391.. The WHODAS 2.0 also makes it possible to identify and monitor the impacts of health or health-related interventions⁵5 Ustün TB, Kostanjsek N, Chatterji S, Rehm J, editores. Measuring health and disability: manual for WHO Disability Assessment Schedule (WHODAS 2.0). Genebra: WHO; 2010..

Among the numerous chronic diseases that cause disability and subsequent alterations in functioning are Human Immunodeficiency Virus (HIV) infection and Acquired Immunodeficiency Syndrome (HIV/AIDS)⁶6 Stenholm S, Westerlund H, Head J, Hyde M, Kawachi I, Pentt J, Kivimäki M, Vahtera J. Comorbidity and Functional Trajectories From Midlife to Old Age: The Health and Retirement Study. J Gerontol A Biol Sci Med Sci 2015; 70(3):332-338.. HIV infection appears to be an experience with a profound biopsychosocial impact, which causes many changes in the individuals’ daily life⁷7 Castanha AR, Coutinho MPL, Saldanha AAW, Oliveira JSC. Bio-psychosocial consequences of AIDS on the Quality of Life of HIV Serum-Positive People. DST J Bras Doenças Sex Transm 2006; 18(2):100-107.. This virus infection will bring psychosocial and behavioral consequences at the moment the individual receives the diagnosis, due to the socially constructed stigmas related to HIV infection. This often leads to depression, social isolation, decreased self-esteem, self-perception, as well as changes in individuals’ occupational activities and social integration⁸8 Carrapato JFL, Resende MHM, Santos NO. People living with HIV/AIDS: diagnosis of a death sentence? Rev Emancipação, Ponta Grossa 2014; 14(2):321-336.. In the biological aspect, HIV infection may cause physiological disturbances and affect individuals’ locomotion and dexterity, leading to changes in the level of independence and ability to work⁷7 Castanha AR, Coutinho MPL, Saldanha AAW, Oliveira JSC. Bio-psychosocial consequences of AIDS on the Quality of Life of HIV Serum-Positive People. DST J Bras Doenças Sex Transm 2006; 18(2):100-107.^,99 Silva LC, Felício EEAA, Cassétte JB, Soares LA, Morais RA, Prado TS, Guimarães DA. Impacto psicossocial do diagnóstico de HIV/aids em idosos atendidos em um serviço público de saúde. Rev Bras Geriatr Gerontol 2015; 18(4):821-833..

HIV/AIDS has a direct impact on functioning of the infected population. Thus, it is important to validate and use an instrument to measure functioning in this population. The validation of the WHODAS 2.0 will provide an overview of functioning from a biopsychosocial perspective, allowing researchers and clinicians to quantify, assess and compare functioning in individuals with HIV/AIDS. Therefore, the objective of this study was to validate the Brazilian version of the WHODAS 2.0 to be used in individuals with HIV/AIDS.

Methods

This is a validation study approved by the Research Ethics Committee. All participants of the research signed an Informed Consent Document. The study sample was selected using convenience sampling, and all participants were invited to collaborate in the research while waiting for attendance at the Clinic of Infectious Diseases at the Federal University of Triângulo Mineiro - UFTM.

To be included in the research, the participants needed to have a diagnosis of HIV/AIDS and to perform their medical follow-up at the Outpatient Clinic of Infectious Diseases. Individuals with coexisting diseases or illnesses associated with HIV/AIDS with potential to interfere in their functioning, as well as individuals with difficulty understanding the applied instruments, were excluded from the sample.

A total of 100 individuals with HIV/AIDS were assessed, which allowed a confidence interval of 95% and a standard deviation of ± 0.34¹⁰10 Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986; 8476(1):307-310..

Instruments

WHODAS 2.0

The WHODAS 2.0 is a generic assessment instrument developed by the WHO to provide a standardized method for measuring health and disability across cultures¹¹11 Castro SS, Leite CF, editores. Measuring health and disability: manual for WHO Disability Assessment Schedule (WHODAS 2.0) [documento na Internet]. Genebra: WHO; 2015. [acessado 2017 Mar 10]. Disponível em: http://apps.who.int/iris/bitstream/10665/43974/19/9788562599514_por.pdf
http://apps.who.int/iris/bitstream/10665... . It has already been translated and validated to be used in numerous languages and in different health conditions. It has seven different versions, which differ in the number of items (12; 36, or a hybrid version, called 12 + 24) and in the application modality (self-administration, interviews, or proxy reports). This instrument addresses functioning according to the following domains: Cognition, Mobility, Self-care, Getting Along, Life Activities and Participation¹¹11 Castro SS, Leite CF, editores. Measuring health and disability: manual for WHO Disability Assessment Schedule (WHODAS 2.0) [documento na Internet]. Genebra: WHO; 2015. [acessado 2017 Mar 10]. Disponível em: http://apps.who.int/iris/bitstream/10665/43974/19/9788562599514_por.pdf
http://apps.who.int/iris/bitstream/10665... .

In the present study, the most complete version with 36 items was administered by interviews. This instrument enables assignment of scores for the six domains of functioning and calculates the total score for functioning, which will range from 0 to 100. The higher the score is, the worse functioning will be. To carry out this study, the interviewer underwent a specific training as recommended by the WHO¹¹11 Castro SS, Leite CF, editores. Measuring health and disability: manual for WHO Disability Assessment Schedule (WHODAS 2.0) [documento na Internet]. Genebra: WHO; 2015. [acessado 2017 Mar 10]. Disponível em: http://apps.who.int/iris/bitstream/10665/43974/19/9788562599514_por.pdf
http://apps.who.int/iris/bitstream/10665... .

WHOQOL-HIV-BREF

It consists of an instrument for assessing Quality of Life (QoL) in persons infected with HIV/AIDS developed by the WHO¹²12 THE WHOQOL-HIV GROUP. WHOQOL-HIV instrument users manual. Genebra: WHO; 2002., which is already validated for use in Brazil¹³13 Zimpel R, Fleck MPA. Quality of life in HIV-positive Brazilians: application and validation of the WHOQOL-HIV, Brazilian version. AIDS Care, Abingdon 2007; 19(7):923-930.. The WHOQOL-HIV-BREF is composed of the same domains as the WHOQOL-100: Physical Health, Psychological Health, Level of Independence, Social Relationships, Environment and Spirituality/Religion. In order to find a less time-consuming but equally valid form of QoL evaluation, the WHO Quality of Life Group developed a reduced version of the WHOQOL-HIV: the WHOQOL-HIV-BREF. This instrument consists of 31 items, two of which with a more general scope (assessment of Overall Quality of Life and General Health Perception) and 29 items representing specific facets. The scores are assigned using a five-point Likert scale, and the results of the specific and general domains are transformed into a range from 0 to 100, according to the original recommendations. Higher results will indicate better QoL¹²12 THE WHOQOL-HIV GROUP. WHOQOL-HIV instrument users manual. Genebra: WHO; 2002..

Procedures

Two trained interviewers administered the above-mentioned questionnaires in a single moment and all the interviews were conducted in reserved rooms to maintain participants' privacy and confidentiality. The first procedure was the completion of the personal data sheet, followed by the application of the WHODAS 2.0 and the WHOQOL-HIV-BREF.

Statistical analysis

Cronbach’s Alpha was used to determine the internal consistency of the WHODAS 2.0. The following Alpha parameters were considered: 0.70-0.90: suitable; and > 0.95: item redundancy¹⁴14 Buist-Bouwman MA, Ormel J, De Graaf R, Vilagut G, Alonso J, Van Sonderen E, Vollebergh WA, ESEMeD/MHEDEA 2000 Investigators. Psychometric properties of the World Health Organization disability assessment schedule used in the European Study of the Epidemiology of mental disorders. Int J Methods Psychiatr Res 2008; 17(4):185-197. .The Spearman’s rank correlation coefficient (r) was used for criterion validity. For this study, r of 0.10 to 0.39 indicated weak/low association; r of 0.40 to 0.69, moderate association; and r from 0.70, strong/high association¹⁵15 Dancey CP, Reidy J. Estatística sem matemática para psicologia. 5ª ed. Porto Alegre: Penso; 2013..

The Spearman’s rank correlation coefficient was used to evaluate the external validity (convergent and divergent). As an assumption, the relational hypothesis (convergent/divergent) between the WHODAS 2.0 questionnaire and the WHOQOL-HIV-BREF domains was established, as shown in Table 1.

All the modalities involved in the present validation process imply a single administration of each instrument to be compared. A significance level of 5% was set for all statistical analyses and no missing values were found in the analyses performed.

Results

Sample characteristics

This study included 100 participants, with a mean age of 42.3 (± 12.04) years, 58% of whom were male. Most participants were single (48%), followed by currently married (16%), separated (20%), divorced (4%), in a stable union (5%), and widowed (7%). Concerning occupation, 32% of the participants were retired; 25% were in paid work; 16% were self-employed; 1% of them were students; and 26% were classified into the “other” group, which includes pensioners, housewives, among others. Regarding the classification of the HIV stages, 54% were classified as asymptomatic, 37% as symptomatic, and 9% as AIDS.

Table 2 shows the means and standard deviations for the domains and Total values for the WHODAS 2.0 and WHOQOL-HIV-BREF instruments.

Psychometric properties

The data of the 36 items were statistically verified in each of their respective domains and organized into tables.

Table 3 displays the outcomes for the internal consistency, which ranged from 0.32 to 0.87.

Table 4 presents data for criterion validity, where a correlation between the WHODAS 2.0 domains and the WHOQOL-HIV-BREF domains was performed, showing that, in general, moderate correlations were found between the questionnaires.

Discussion

Admittedly, the WHODAS 2.0 has adequate internal consistency for most research purposes and is consistent with published works with the same objectives in other countries¹⁶16 Kutlay S, Küçükdeveci AA, Elhan AH, Oztuna D, Koç N, Tennant A. Validation of the World Health Organization disability assessment schedule II (WHODAS-II) in patients with osteoarthritis. Rheumatol Int 2011; 31(3):339-346.

17 Magistrale G, Pisani V, Argento O, Incerti CC, Bozzali M, Cadavid D, Caltagirone C, Medori R, DeLuca J, Nocentini U. Validation of the World Health Organization Disability Assessment Schedule II (WHODAS-II) in patients with multiple sclerosis. Mult Scler 2015; 21(4):448-456.

18 Tazaki M, Yamaguchi T, Yatsunami M, Nakane Y. Measuring functional health among the elderly: development of the Japanese version of the World Health Organization Disability Assessment Schedule II. Int J Rehabil Research 2014; 37(1):48-53.^-1919 Chiu TY, Yen CF, Chou CH, Lin JD, Hwang AW, Liao HF, Chi WC. Development of traditional Chinese version of World Health Organization Disability Assessment Schedule 2.0 36--item (WHODAS 2.0) in Taiwan: Validity and reliability analyses. Res Dev Disabil 2014; 35(11):2812-2820..

The Self-care domain showed Alpha coefficient lower than expected, indicating low internal consistency. Therefore, the information obtained from this domain should be used in a careful manner, as it may not present reliability when measuring the construct.

The internal consistency of the Life Activities domain may have been low due to the profile of the studied population and the non-applicability of some items in domain 5 (“school or work activities”), as most participants were retired. Therefore, the items related to “work” had their information negatively affected. Thus, we suggest the use of the 32-item version, which was used in 6 studies found in the literature¹⁹19 Chiu TY, Yen CF, Chou CH, Lin JD, Hwang AW, Liao HF, Chi WC. Development of traditional Chinese version of World Health Organization Disability Assessment Schedule 2.0 36--item (WHODAS 2.0) in Taiwan: Validity and reliability analyses. Res Dev Disabil 2014; 35(11):2812-2820.

20 Garin O, Ayuso-Mateos J, Almansa J, Nieto M, Chatterji S, Vilagut G, Alonso J, Cieza A, Svetskova O, Burger H, Racca V, Francescutti C, Vieta E, Kostanjsek N, Raggi A, Leonardi M, Ferrer M, MHADIE consortium. Validation of the "World Health Organization Disability Assessment Schedule, WHODAS-2" in patients with chronic diseases. Health Qual Life Outcomes 2010; 8:51.

21 Meesters JJL, Verhoef J, Liem ISL, Putter H, Vliet Vlieland TPM. Validity and responsiveness of the World Health Organization Disability Assessment Schedule II to assess disability in rheumatoid arthritis patients. Rheumatology (Oxford) 2010; 49(2):326-333.

22 Guilera G, Gómez-Benito J, Pino O, Rojo E, Vieta E, Cuesta MJ, Purdon SE, Bernardo M, Crespo-Facorro B, Franco M, Martínez-Arán A, Safont G, Tabarés-Seisdedos R, Rejas J, Spanish Working Group in Cognitive Function. Disability in bipolar I disorder: the 36-item World Health Organization Disability Assessment Schedule 2.0. J Affect Disord 2015; 174:353-360.

23 Wolf AC, Tate RL, Lannin NA, Middleton J, Lane-Brown A, Cameron ID. The World Health Organization Disability Assessment Scale, WHODAS II: reliability and validity in the measurement of activity and participation in a spinal cord injury population. J Rehabil Med 2012; 44(9):747-755.^-2424 Küçükdeveci AA, Kutlay S, Yildizlar D, Öztuna D, Elhan AH, Tennant A. The reliability and validity of the World Health Organization Disability Assessment Schedule (WHODAS-II) in stroke. Disabil Rehabil 2013; 35(3):214-220..

In the present study, negative correlation coefficients were found in most associations. This happened because the WHODAS 2.0 and the WHOQOL-HIV-BREF produce inverse scores. Regarding the intensity of the coefficients ratio, there were no strong correlations between the instruments, showing mostly moderate correlations between the domains. Notably, the results show that the instruments correlate with each other, are complementary, and are used for different purposes: the WHODAS 2.0 assesses functioning measures, whereas the WHOQOL-HIV-BREF assesses subjective measures of well-being. Also, the domains of each instrument are similar, but not identical.

In connection with convergent validity, we can observe that the Cognition domain of the WHODAS 2.0 showed a moderate significant correlation with the Psychological, Environmental and Total domains of the WHOQOL-HIV-BREF. Similarly, the Mobility domain had a moderate and significant correlation with the Level of Independence domain. The General Disability Score of the WHODAS showed correlation with the Total domain of the WHOQOL-HIV-BREF. Thus, the results described above support the convergent validity of the WHODAS.

In order to verify the divergent validity, some unrelated domains were chosen to illustrate this psychometric property. There were no significant correlations between the Cognitive and Mobility domains of the WHODAS 2.0 and the Physical domain of the WHOQOL-HIV-BREF; between the WHODAS 2.0 Self-care domain and the WHOQOL-HIV-BREF Social Relationships and Spirituality/Religion domains; and between the WHODAS 2.0 Getting Along domain and the WHOQOL-HIV-BREF Physical and Environmental domains.

Similar to other studies found in the literature that used the 36-item version, the validation of the Brazilian version of the WHODAS 2.0 showed overall satisfactory psychometric properties, allowing its use to assess functioning in individuals with HIV/AIDS¹⁶16 Kutlay S, Küçükdeveci AA, Elhan AH, Oztuna D, Koç N, Tennant A. Validation of the World Health Organization disability assessment schedule II (WHODAS-II) in patients with osteoarthritis. Rheumatol Int 2011; 31(3):339-346.^,1818 Tazaki M, Yamaguchi T, Yatsunami M, Nakane Y. Measuring functional health among the elderly: development of the Japanese version of the World Health Organization Disability Assessment Schedule II. Int J Rehabil Research 2014; 37(1):48-53.^,2020 Garin O, Ayuso-Mateos J, Almansa J, Nieto M, Chatterji S, Vilagut G, Alonso J, Cieza A, Svetskova O, Burger H, Racca V, Francescutti C, Vieta E, Kostanjsek N, Raggi A, Leonardi M, Ferrer M, MHADIE consortium. Validation of the "World Health Organization Disability Assessment Schedule, WHODAS-2" in patients with chronic diseases. Health Qual Life Outcomes 2010; 8:51.^,2525 Federici S, Meloni F, Mancini A, Lauriola M, Olivetti Belardinelli M. World Health Organization Disability Assessment Schedule II: contribution to the Italian Validation. Disabil Rehabil 2009; 31(7):553-564.^,2626 Downing NR, Kim JI, Williams KJ, Long JD, Mills JA, Paulsen JS. WHODAS 2.0 in prodromal Huntington disease: Measures of functioning in neuropsychiatric disease. Eur J Hum Genet 2014; 22(8):958-963..

Among the positive points is the great contribution of this study to the scientific literature, as this is the first instrument translated into Brazilian Portuguese that evaluates functioning in the HIV/AIDS population in a comprehensive manner and in accordance with the guidelines of the WHO. More importantly, this study enables the use of functioning as a health indicator for this population. So far, this construct could not have been measured, as there were no instruments that would approach the biopsychosocial model. The two most typical health indicators - mortality and morbidity - associated with functioning would be more adequate for the development of health intervention strategies²⁷27 Stucki G, Bickenbach J. Functioning: the third health indicator in the health system and the key indicator for rehabilitation. Eur J Phys Rehabil Med 2017; 53(1):134-138.. Knowing how people live is more important than knowing why they die. Using functioning as one of the main health indicators will improve service planning²⁸28 Cieza A, Sabariego C, Bickenbach J, Chatterjj S. Rethinking Disability. BMC Med 2018; 16(1):14. as well as care and health policies for individuals with HIV/AIDS. The progressive increase in the survival of individuals with HIV/AIDS supports this statement⁸8 Carrapato JFL, Resende MHM, Santos NO. People living with HIV/AIDS: diagnosis of a death sentence? Rev Emancipação, Ponta Grossa 2014; 14(2):321-336.. Thus, when presenting the psychometric properties of the WHODAS 2.0 administered to individuals with this health condition, this instrument will enable functioning to be used as an indicator for health management.

In conclusion, the Brazilian version of the WHODAS 2.0 with 36 items showed that psychometric properties, internal consistency, convergent validity and divergent validity are reliable and valid for the assessment of functioning in individuals with HIV/AIDS. It is important to emphasize the possibility of using a shorter version, with 32 items, due to the inapplicability of some items, as well as the careful use the items in the Self-care domain.

References

Publication Dates

History