Disability and Rehabilitation

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World Health Organization disability assessment

schedule 2.0: An international systematic review

Stefano Federici, Marco Bracalenti, Fabio Meloni & Juan V. Luciano

To cite this article: Stefano Federici, Marco Bracalenti, Fabio Meloni & Juan V. Luciano (2016):
World Health Organization disability assessment schedule 2.0: An international systematic
review, Disability and Rehabilitation, DOI: 10.1080/09638288.2016.1223177

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DISABILITY AND REHABILITATION, 2016
http://dx.doi.org/10.1080/09638288.2016.1223177

REVIEW

World Health Organization disability assessment schedule 2.0: An international

systematic review
Stefano Federicia , Marco Bracalentia , Fabio Melonia and Juan V. Lucianob,c
a
Department of Philosophy, Social & Human Sciences and Education, University of Perugia, Perugia, Italy; bTeaching, Research & Innovation
Unit, Parc Sanitari Sant Joan De D
eu, St. Boi De Llobregat, Spain; cPrimary Care Prevention and Health Promotion Research Network (RedIAPP),
Madrid, Spain

ABSTRACT ARTICLE HISTORY

Purpose: This systematic review examines research and practical applications of the World Health Received 16 April 2016
Organization Disability Assessment Schedule (WHODAS 2.0) as a basis for establishing specific criteria for Revised 4 August 2016
evaluating relevant international scientific literature. The aims were to establish the extent of international Accepted 8 August 2016
dissemination and use of WHODAS 2.0 and analyze psychometric research on its various translations and
adaptations. In particular, we wanted to highlight which psychometric features have been investigated, KEYWORDS
focusing on the factor structure, reliability, and validity of this instrument. WHODAS 2.0; systematic
Method: Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) method- review; PRISMA; disability
ology, we conducted a search for publications focused on “whodas” using the ProQuest, PubMed, and measurement; ICF; DSM-5
Google Scholar electronic databases.
Results: We identified 810 studies from 94 countries published between 1999 and 2015. WHODAS 2.0 has
been translated into 47 languages and dialects and used in 27 areas of research (40% in psychiatry).
Conclusions: The growing number of studies indicates increasing interest in the WHODAS 2.0 for assess-
ing individual functioning and disability in different settings and individual health conditions. The
WHODAS 2.0 shows strong correlations with several other measures of activity limitations; probably due
to the fact that it shares the same disability latent variable with them.

ä IMPLICATIONS FOR REHABILITATION

WHODAS 2.0 seems to be a valid, reliable self-report instrument for the assessment of disability.

The increasing interest in use of the WHODAS 2.0 extends to rehabilitation and life sciences rather
than being limited to psychiatry.

WHODAS 2.0 is suitable for assessing health status and disability in a variety of settings and
populations.

A critical issue for rehabilitation is that a single “minimal clinically important .difference” score for the
WHODAS 2.0 has not yet been established.

Introduction pathological model of disability [6,7] – hugely influential in the

The International Classification of Functioning, Disability and Health
(ICF) [1] describes functioning and disability as the outcome of a
complex, multidimensional interaction between a person’s health
condition(s) and context (environmental and personal factors).
Positive or neutral aspects of those interactions are referred to as
functioning; negative aspects as disability. More specifically, dis-
ability can be described as arising out of limitations on activity
and restrictions on participation that are determined by the inter-
action between bodily functioning, structural impairments, and an
unhelpful context. Unlike previous classification systems, the ICF
does not describe disability exclusively from the viewpoint of
health professionals; instead it uses the “biopsychosocial
approach.” This represents a new paradigm,[2] shifting from the
previous ICIDH: International Classification of Impairments,
Disabilities, and Handicaps,[3] which failed to integrate the social
model of disability.[4,5] The ICIDH precisely followed Nagi’s
United States from the 1960s,[8] and which was also the basis for
the “disablement process” of Verbrugge and Jette [9] – medicaliz-
ing disability.[10] Conversely, the ICF focuses on the context-
dependent impact of disability on a person’s functioning and is
neutral with respect to the etiopathological aspects of disability.
This implies that the ICF is indifferent towards the hierarchical
order of possible health states based on medical standards, mov-
ing “away from being a consequence of disease classification”.[1]
This complex, dynamic, multidimensional, and contested con-
cept of disability [11] has profound implications for the measure-
ment of disability. Any empirical measurement of disability
assumes an operational definition “that tells us what to observe
and how to describe it”.[12] While the ICF model does provide
standardized language with which to frame disability and a com-
prehensive conceptual description of health related states, it does
not provide specific operationalization of the more general con-
cepts associated with disability for developing questions.[13]

CONTACT Stefano Federici stefano.federici@unipg.it Department of Philosophy, Social & Human Sciences and Education, University of Perugia, Piazza G.
Ermini 1, Perugia 06123, Italy
Supplemental data for this article can be accessed here
ß 2016 Informa UK Limited, trading as Taylor & Francis Group
2 S. FEDERICI ET AL.
For example, in a bilingual context where the second language
is a sign language, deafness would emerge only as an impairment
(i.e., as a structural and functional body dysfunction). However, in
contexts where this sign language is only spoken by a minority,
deafness would be considered not only as an impairment but also
as a restriction on participation.[14,15] In this case, a disability
assessment tool designed to evaluate restrictions on participation
would register little evidence of disability in the bilingual context
and, in contrast, much greater disability in the monolingual con-
text, despite the similar epidemic diffusion of deafness in the two
contexts.[16]
In recognition of this context dependency, the ICF does not
prescribe specific measurement tools; as Zola argued,[17] any
attempt to identify standard indices of disability represents a futile
attempt to define disability as a fixed, dichotomous concept
rather than as the fluid, continuous experience it is in practice.
Although disability is neither a fixed nor dichotomous concept,
this does not mean it cannot be measured: the clearness of the
purpose of the measurement ensures identification of the most
suitable tools.
Another well-known paradox in measuring disability arises from
the fact that an individual’s understanding of his or her well-being
may not accord with the evaluations of medical experts. Sen [18]
has noted the conceptual difference between perception and
observation of health. There is often discrepancy between an indi-
vidual’s subjective view of his or her health, based on personal per-
ceptions, and the views of doctors or professionals, which are
based on objective data.[19] Many people with severe disability
often claim that they have an acceptable or even good quality of
life, although there is a widespread assumption that if people have
a disability they cannot enjoy a state of well-being.[20,21] Albrecht
and Devlieger [22] stated that the “disability paradox” implies that
personal experience with disability is an important aspect of any
assessment of disability and hence assessments of it should com-
bine objective observations with subjective, self-report data.
In June 1999, in order to address the issue of an effective
assessment of disability, the World Health Organization (WHO) dis-
seminated a beta version of a generic assessment instrument: the
WHO Disability Assessment Schedule II (WHODAS II). WHODAS II
provided a cross-cultural, standardized method for measuring limi-
tations and restrictions on individuals’ activities and participation
in their society in a way which was independent of medical diag-
nosis. The beta version of WHODAS II was based on the WHO
Psychiatric Disability Assessment Schedule [23] which was
designed to assess the extent of disability associated with a psy-
chiatric condition; it was developed for use in a field trial phase
(version 3.1a Phase Two). A guide to using WHODAS II was pub-
lished in 2004.[24] The publication of the Manual in 2010 [25]
marked the final version, which is referred to under the acronym
WHODAS 2.0.
WHODAS 2.0 was developed from a large pool of ICF items
which were subjected to field trials in 19 countries.[26] ICF experts
reviewed all the psychometric and qualitative data from these tri-
als and selected 36 items to represent the ICF’s six activity and
participation domains:

Cognition – understanding and communicating (six items).

Mobility – moving and getting around (five items).

Self-care – hygiene, dressing, eating, and being alone (four
items).

Getting along – interacting with other people (five items).

Life activities – domestic responsibilities, leisure, work, and
school (eight items).

Participation – joining in community activities (eight
items).
A 12-item version consisting of two items from each domain
(Understanding and communicating, items 3 and 6; Getting
around, items 1 and 7; Self-care, items 8 and 9; Getting Along
with People, items 10 and 11; Life activities, items 2 and 12;
Participation in society, items 4 and 5) was also produced. Scores
on the 12-item version account for 85% of the variance in scores
on the full 36-item version. Seven paper-based versions of
WHODAS 2.0 were developed:

Three 36-item versions: Interview-administered, self-admin-
istered, and proxy-administered (knowledgeable
informants).

Three 12-item versions: Interview-administered, self-admin-
istered, and proxy-administered.

One 12 þ 24-item version, interview-administered.
A version designed specifically for use with children (WHODAS-
Child) was developed in 2013 by the DSM-5 Impairment/Disability
workgroup.[27] This version uses phrasing which is easily under-
stood by children and their families, and consistent with the basic
descriptions of child disability in the children and youth version of
the ICF.[28]
Unlike the most commonly used measuring instruments,
WHODAS 2.0 rates disability from the respondent’s subjective per-
spective. The respondent is asked to indicate how much
“difficulty” he or she experiences (none, mild, moderate, severe,
and extreme) in the normal performance of a given activity, taking
into account the use of support or assistive devices and/or the
help of a caregiver (aids) where applicable. For any item rated
greater than none, a follow-up question is used to elicit informa-
tion about the frequency with which difficulty is experienced. The
respondent is asked on how many days in the last 30 he or she
experienced difficulty; responses are given on a five-point scale:
(1) only 1 day; (2) up to a week ¼ from 2 to 7 d; (3) up to 2 week-
s ¼ from 8 to 14 d; (4) more than 2 weeks ¼ from 15 to 29 d; (5)
every day ¼30 d.
Next, the respondent is asked how much the difficulties have
interfered with his or her life. Respondents are asked to answer
with reference to the following:
1. Degree of difficulty (increase in effort, discomfort or pain,
slowness, or changes in the way the person does the
activity).
2. Health conditions (disease or illness, injury, mental or emo-
tional problems, or problems related to alcohol or drug
abuse).
3. The last 30 d.
4. Averaging “good” and “bad” days.
5. The way in which he or she normally performs the activity.
6. Items that refer to activities not experienced in the past 30 d
are not rated.
The structure and features of WHODAS 2.0 – i.e., its context
invariance and independence from medical diagnosis, and equiva-
lence of the six domains of functioning and disability – are con-
ceptually compatible not only with the biopsychosocial approach
and the ICF but also with the atheoretical and polythetic model of
the Diagnostic and Statistical Manual of Mental Disorders (DSM)
developed by the American Psychiatric Association (APA).[29,30]
The context-dependent nature of psychiatric disorders means that
the patient’s perspective on his or her own functioning is particu-
larly relevant to psychiatric assessment.[29] Self-evaluations are a
better method of capturing an individual’s experiences and con-
textual background than a professional’s assessment, which may
be influenced by his or her cultural bias.
It is, therefore, not surprising that the first edition of WHODAS,
the WHO Psychiatric Disability Assessment Schedule,[23] was spe-
cifically designed to assess the level of disability associated with a

psychiatric condition. Its prevalent use in the psychiatric context
explains why the fifth edition of the DSM indicates the WHODAS
2.0 as the most suitable tool for the assessment of functioning in
psychiatric patients.
In the last 15 years, the WHODAS 2.0 has also acquired greater
significance in collecting prevalence data on disability. In order to
harmonize disability statistics worldwide, a workgroup [31] was
formed to plan and implement analyses of the six measure ques-
tions developed by the Washington Group on Disability Statistics
(WG) [32] – formed as a result of the United Nations International
Seminar on Measurement of Disability that took place in New
York in June 2001: the WHODAS 2.0 six domains of activity and
participation, and the World Health Survey modules.[33] Disability
question short sets were outlined [31] that overcame the limita-
tions of the six WG census questions. Although created on the
basis of the ICF framework, the WG short questions discard con-
textual factors, indeed. Incorporating the six domains into the WG
questions enable studying the lived experience of health beyond
measuring the consequence of diseases.[2]
Purpose
The aim of this systematic review was to examine the use of
WHODAS 2.0 in international scientific literature between 1999 and
2015. In particular, we analyzed the version, language, and psycho-
metric properties of the WHODAS 2.0 as well as the countries and
research fields in which it has been used. We also analyzed the
design, purpose, and results of studies using WHODAS 2.0.
Method
This study followed the checklist in the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA) statement
(www.prisma-statement.org).[34,35]
Eligibility criteria
We considered books, book chapters, conference papers, confer-
ence proceedings, instruction manuals, and journal articles for
which the full text or abstract was published in at least one of the
five major European languages (English, Spanish, Portuguese,
German, and French) and which focused on at least one of the
WHODAS versions developed since 1999. Studies which explicitly
reported use of the WHO Psychiatric Disability Assessment
Schedule (WHODAS-I or WHO/DAS) [23] or the WHO Short
Disability Assessment Schedule (WHODAS-S) [36] were excluded
from analysis. We also excluded studies whose bibliography only
included reference to WHO 1988 [23] or Janca et al.[36] Finally, we
excluded doctoral dissertations and work published without an
abstract in one of the five major European languages cited above.
Information sources
We identified publications by searching the PubMed, EBSCO, and
Google Scholar electronic databases, and by scanning reference
lists of pertinent review articles, editorials, and hand-
books.[24–26,37–72] The last search was run on 31 December
2015.
Search
We used the following search terms in all fields: (whodas OR who-
das OR who/das OR “world health organization disability assess-
ment schedule”).
WHODAS 2.0: AN INTERNATIONAL SYSTEMATIC REVIEW 3
Study selection
Eligibility assessment was performed independently in a blinded,
standardized manner by authors S. F. and M. B. The first screening
was based on the article abstracts. The next selection was based
on the full text of the documents. Disagreements between
reviewers were resolved by discussion to reach a consensus.
Data collection process
We developed a data extraction sheet. This was pilot-tested on
eleven randomly-selected included studies and refined accord-
ingly. S. F. and M. B. extracted the data from the included studies
and checked them. Disagreements were resolved by discussion
between the authors.
Data items
Information was extracted on (1) year of publication; (2) study
design (i.e., cross-sectional study, longitudinal study, review, etc.);
(3) country where the study was conducted; (4) research field; (5)
sample size; (6) sample type (i.e., general population, older people,
depressed people, etc.); (7) purpose of the study; (8) WHODAS 2.0
version used (i.e., 12-item, 36-item, etc.); (9) language in which
WHODAS 2.0 was used; (10) psychometric properties of WHODAS
2.0; (11) other measures used in the study; (12) publication type
(i.e., journal article, conference proceedings, etc.) (see
Supplementary Table S1).
Results
Study selection
The number of publications retrieved from each electronic data-
base was as follows, ProQuest: 709, PubMed: 522, Google Scholar:
4588 – a total of 5819 publications. By following up references
from relevant review articles, editorials and handbooks, we identi-
fied an additional 23 papers that met the inclusion criteria. Taking
duplication into account, there were 4680 records; 3427 were dis-
carded because the abstract was not available in one of the five
major European languages (English, Spanish, Portuguese, German,
and French) or did not focus on the content of interest, or
because the product was only web content (e.g., blogs, discussion
boards, web documents, etc.). The full texts of the remaining 1253
citations were examined in more detail and as a result an add-
itional 443 studies which did not meet the inclusion criteria were
excluded from the analysis.
The remaining 810 records met inclusion criteria and were
included in the systematic review. The selection process is sum-
marized in a flow diagram according to PRISMA [34] guidelines
(Figure 1).
Study characteristics
We investigated the following variables in the 810 selected stud-
ies: study design; country where the study was conducted;
research area; sample size; sample type (e.g., general population,
older people, etc.); purpose of the study; the WHODAS 2.0 version
used; the language in which WHODAS 2.0 was used; the psycho-
metric properties of WHODAS 2.0 where reported; the other meas-
ures used in the study; publication type (i.e., journal article,
conference proceedings, etc.). Supplementary Table S1 summa-
rizes the information extracted from the selected studies (see sub-
section “Data items” above); Supplementary Table S2 displays
4 S. FEDERICI ET AL.
Figure 1. Four-phase flow diagram of the systematic review according to PRISMA.[34]
frequencies (number and percentage) for the six main study char-
acteristics of the included studies: year of publication; study
design; country where the study was conducted; research field;
WHODAS 2.0 version used; publication type.
The number of included studies increased from 1999 onwards.
More than 50% of the studies were published between 2013 and
2015. This percentage remains unchanged (>50% in the last three
years) even when studies in the field of psychiatry (n ¼ 328; 40%)
are excluded on the grounds that the release in 2013 of DSM-5
[29] – which recommends WHODAS 2.0 for assessment of disabil-
ity in adults aged 18 years and older with mental disorders –
might have affected the global trend (Figure 2; Supplementary
Table S2).
Ninety-four percent (n ¼ 761) of the publications were journal
articles (Supplementary Table S1); 4% (n ¼ 29) were conference
proceedings [72–100]; 2% book chapters (n ¼ 16) [71,101–115]; 0.
4% (n ¼ 3) books [24,25,116]; and 0.1% (n ¼ 1) an encyclopedia
term [117] (Supplementary Table S2).
The research groups responsible for the selected studies came
from 94 countries. The most heavily represented countries
(responsible for 571 studies, 44%) were the United States of
America (n ¼ 162, 12%), Australia (n ¼ 81, 6%), Spain (n ¼ 77, 6%),
Italy (n ¼ 69, 5%), India (n ¼ 66, 5%), the Netherlands (n ¼ 62, 5%),
and China (n ¼ 54, 4%) (Supplementary Tables S1 and S2).
According to the Manual for WHO Disability Assessment
Schedule,[25] WHODAS 2.0 is available in more than 30 languages.
We found that WHODAS 2.0 was administered in 47 languages and
dialects; the following is a list of the first reported translations in
each case: Amharic,[118] Arabic,[119] Bengali,[120] Chinese,[121]
Danish,[122] Dari,[123] Dutch,[124] English,[125] Estonian,[126]
Farsi,[127] French,[128] Georgian,[129] German,[130] Greek,[131]
Haitian Creole,[132] Hebrew,[133] Hindi,[134] Indonesian,[135]
Italian,[136] Japanese,[137] Kannada,[138] Kinyarwanda,[139]
Korean,[140] Krio,[141] Latvian,[83] Luganda,[142] Lusoga,[143]
Malayalam,[144] Nepali,[145] Norwegian,[146] Polish,[147]
Portuguese,[148] Russian,[149] Slovenian,[150] Spanish,[151]
Swedish,[152] Tamil,[153] Thai,[154] Tok Pisin,[155] Turkish,[156]
Twi,[157] Ukrainian,[149] Urdu,[158] Xhosa,[159] Xitsonga,[160]
Yoruba,[161] and Zulu [162] (Supplementary Table S1).
Information about the types of study is presented in
Supplementary Tables S1 and S2: 60% (n ¼ 482) were cross-sec-
tional studies; 11% (n ¼ 89) were longitudinal studies; 8% (n ¼ 61)
were randomized controlled trials; 4% (n ¼ 36) reviews; 5% (n ¼ 41)
theoretical or evaluative research; 3% (n ¼ 27) follow-up studies;
3% (n ¼ 22) non-randomized controlled trials; 2% (n ¼ 17) random-
ized clinical trials; 1% (n ¼ 10) study protocols; 1% (n ¼ 7) qualita-
tive studies; 1% (n ¼ 6) data comparisons; 1% (n ¼ 6) guides; 0.4%
(n ¼ 3) agreement studies (study of agreement between two or
more judges belonging to a focus group or to an expert panel); 0.
2% (n ¼ 2) case studies; and 0.1% (n ¼ 1) Delphi surveys.
WHODAS 2.0 was used in 27 research fields; most frequently in
psychiatry (n ¼ 328, 40%);[27,41,50,53,54,68,71,79,83–85,91–94,97,
102, 109, 110, 115, 118, 121, 122, 123, 128, 129, 132, 145, 155–158, 161,
163–457] geriatrics (n ¼ 121, 14,9%);[90,95,100,106,111,120,127,137,
138,153,154,458–567] neurology (n ¼ 74, 9%) [51,58,64,69,74,76,77,
81, 88, 89, 98, 99,568–629]; disability and rehabilitation (n ¼ 71, 9%;
[24–26, 44, 52, 55–57, 73, 78, 80, 82, 96, 104, 107, 108, 116, 117, 119, 126,
134,136,143,150,152,630–675]), health sciences (n ¼ 45, 6%) [39,59,
60, 103, 105, 112, 114, 133, 142, 160, 162, 676–709]; and epidemiology
(n ¼ 29, 4%).[48,70,87,101,159,710–733] Together, these fields
accounted for 82% of all studies (n ¼ 668). References for each of
the 27 research fields are reported in Supplementary Table S1 and
frequencies (number and percentage) for each field are displayed
in Supplementary Table S2.

Figure 2. Number of selected studies published per year.  although the last search was run on 31 December 2015, eight journal articles
[53,285,313,499,556,598,656,689] dated 2016 matching our criteria were already available online.
Taken together, the research studies involved thousands of
participants worldwide (Supplementary Table S1). Several studies
recruited subjects cross-sectionally or longitudinally in cohorts
from international surveys (e.g., European Study on the
Epidemiology of Mental Disorders – ESEMeD [176,177,182,195,201,
205–207,235,236,366,413]; WHO Study on global AGEing and adult
health – SAGE [120,162,473,491,511,528,552,565,676,686,687,724,
734,735]; 10/66 Dementia Research Group [90,100,111,153,212,489,
501, 508, 514, 516–517, 530–534, 536, 540, 548–550, 555, 557, 564]) or
national surveys (e.g., the Netherlands Study of Depression and
Anxiety – NESDA [58, 282, 285, 286, 295, 296, 313, 314, 363, 367, 373,
430–432,435–437,440,441]).
Twenty-nine percent (n ¼ 243) of the selected studies did not
report which version of WHODAS 2.0 was administered.[38–44,47,
49, 50, 58–64, 67–69, 72, 74, 75, 78, 80, 83, 85, 87, 91, 93–95, 97–99, 102,
106–108,122,132,155,158,168–170,174,175,181,183,184,190,192,195,
197,199,200,204,208,211,222,225,229,234,244,246–249,252,258,262,
263, 270–272, 275–285, 287, 288, 298, 299, 301–308, 312, 314–320,
327–329, 334, 336, 337, 341, 345, 357, 358, 363, 366, 370–373, 375–377,
386,388,394,399,400,405,407,409,412,414,417–419,421,430,431,434,
437,438,441,443,445–447,455,458,459,461,465,468,469,476,477,496,
497, 500, 501, 504–507, 512, 513, 516–517, 520, 522, 525, 534, 537–539,
541,547,551,566–569,574,575,581,582,585,598,599,601,603,619,626,
636,641,645,647,648,652,663,665,666,676,677,681–683,685,688,693,
695,696,704,706,708–710,721,725,726,728,729,733,735–751]
Thirty percent (n ¼ 248) used the 36-item version of WHODAS
2.0 [24–26,45,46,48,51,53–57,65,66,70,71,76,77,81,82,86,88,89,96,
101, 103, 110, 112, 114–121, 124, 125, 127, 130, 131, 136–138, 143, 144,
146–148,150–153,156,159,160,163,164,167,189,196,198,203,210,213,
217–220,223,226–228,232,233,240,242,243,253,254,265,266,268,269,
286,290,295,296,300,310,311,313,331,332,335,338,339,348,349,351,
361,367,374,385,395,398,403,408,410,411,423,432,435,436,439,440,
462,466,467,472,480,486,487,490,509,510,521,523,524,527,529,546,
560, 572, 573, 577, 579, 583, 586, 588–597, 600, 602, 604–618, 622–625,
627,629,631,632,634,638,639,644,649,650,657,659,660,662,668–670,
672–674, 679, 680, 690–692, 700, 702, 705, 713, 722, 752–799]; 29,5%
(n ¼ 244) the 12-item version [24–26,37,48,52,55,73,79,84,90,92,100,
105,109,111,114,116,117,123,129,134,137,141,142,145,157,162,166,
WHODAS 2.0: AN INTERNATIONAL SYSTEMATIC REVIEW 5
171,180,185,186,188,191,194,209,212,215,221,224,237–239,241,245,
250,251,256,257,260,261,264,265,267,273,274,289,291–294,297,309,
322–326, 333, 342–344, 353, 354, 356, 359, 360, 364, 365, 368, 369, 379,
382–384, 387, 389–393, 396, 401, 402, 404, 420, 422, 424–428, 442, 444,
449, 451–454, 456, 460, 463, 464, 470, 473–475, 478, 479, 481–485, 488,
489,491–494,498,499,508,511,514,515,518,519,526,528,530–533,536,
540, 542–545, 549, 550, 552, 553, 555–559, 561–565, 570, 571, 576, 578,
584,586,587,620,621,628,630,635,637,642–644,646,651,653–655,658,
661,664,667,675,678,686,687,689,690,692,694,699,701,703,707,711,
712, 715–720, 723, 724, 727, 731, 732, 734, 800–827]; and 1% (n ¼ 6)
WHODAS-Child.[27,139,828–831]
Three percent (n ¼ 24) of the selected studies administered the
World Mental Health (WMH) Survey Initiative version, WMH-
WHODAS.[104,133,161,176–179,193,201,202,205–207,216,321,355,
397,416,429,671,730,832–834] The WMH Survey Initiative is a pro-
ject organized by the Assessment, Classification, and
Epidemiology (ACE) Group at the WHO and its purpose is to
obtain accurate information about the prevalence and correlates
of mental disorders, substance use disorder, and behavioral disor-
ders in countries in all WHO regions (http://www.hcp.med.harvard.
edu/wmh/). WMH-WHODAS is a modified version of WHODAS 2.0
which was added to the revised version of the Composite
International Diagnostic Interview (WMH-CIDI), a comprehensive,
structured diagnostic interview for assessing mental disorders.
[177]
Finally, 7% (n ¼ 61) of the studies administered a subset of
WHODAS 2.0 items selected for their relevance to the research in
question.[113,126,128,135,149,154,165,172,173,182,187,214,230,231,
235,236,255,259,330,340,346,347,350,352,362,378,380,381,406,413,
415,433,448,450,457,471,495,502,503,535,548,554,580,584,631,633,
640,656,684,697,698,714,835–843]
Forty-eight of the 810 selected studies reported the psycho-
metric properties of WHODAS 2.0.[24,25,80,86,121,124,125,130,136,
137,139,143,144,151,156,188,206,207,254,268,269,322–324,332,502,
519,549,550,571,577,587,595,622,623,638,640,650,660,671,679,711,
723,736,764,769,799,812]
Internal consistency: Twenty-eight studies [25, 121, 124, 125, 130,
136,137,139,144,151,156,254,268,269,324,519,549,571,577,595,622,
6 S. FEDERICI ET AL.
638, 640, 671, 679, 736, 769, 799] reported the internal consistency
(Cronbach’s alpha) of WHODAS 2.0.[25]
As shown in Table 1, the alpha coefficients for the total score
indicate that the 36-item and WMH-WHODAS versions have excel-
lent internal consistency in all languages (alpha 0.90). In the
case of the 12-item version, the values indicate excellent consist-
ency except for the Portuguese version [519] (alpha ¼0.86), the
Italian version [620] (alpha ¼0.88), and the Spanish version admin-
istered in Spain [324] (alpha ¼0.89). The WHODAS-Child had good
overall internal consistency (alpha ¼0.84) [139] but in several
studies internal consistency was very poor in some domains. In
particular, Federici et al.,[136,151,671] Chavez et al. [136,151,671]
and von Korff et al. [136, 151, 671] found a very low values of
Cronbach’s alpha ( 0.50) for the “self-care” domain.
Factor structure: According to the Manual for WHO Disability
Assessment Schedule,[25] most items in the 36-item version load
on their theoretically assigned domains, confirming the unidimen-
sionality of all domains; the exception was leisure items in domain
5 (Life activities), which actually loaded on domain 6
€
(Participation). According to Ustun et al.,[26] the 36-item version
has a second-order factor structure in all cultures and populations
tested. The first level consists of a general disability factor and the
second level comprises the six disability domains. Several explora-
tory and confirmatory factor analyses of the instrument have been
carried out,[207, 549] with different sample types and languages,
such as the Chinese version,[640,679,799] the Italian version,[136,
595] the Spanish version,[254, 268, 269, 650] and the German ver-
sion.[130] K€ uç€
ukdeveci et al.,[86] who administered the 36-item
Turkish version, found that four domains included items that
strongly loaded on the respective domain, while one item in
“Getting along” and six items in “Life activities” failed to
adequately load, suggesting that the factor structure of the
WHODAS 2.0 in stroke patients is not supported. Scorza et al.
[139] confirmed the six-factor structure of the Kinyarwanda ver-
sion of WHODAS-Child. With regard to the 12-item version, Rehm
et al. [664] reported an excellent fit for a one-factor structure,
with moderate-to-strong factor loadings for the items on a latent
“global disability” factor. Similar results were found in other stud-
ies.[324,571,711,723,812] The 12-item version accounts for 80% of
the variance of the 36-item version.[25,26]
Test–retest reliability: McKibbin et al. [338] reported that the
intra-class correlation coefficient (ICC) of WHODAS 2.0 scores was
0.89 in a sample of older persons with schizophrenia assessed
twice with an inter-test interval of 12 weeks. Guilera et al. [269]
obtained an ICC of 0.92 in a similar sample. Tests in samples of
people with arthritis [218] and adults with acquired hearing loss
[125] also reported high test–retest reliability for all the WHODAS
2.0 domain scores. A study of Chinese adults with various types of
disability reported an ICC of 0.80.[679] Finally, a test–retest study
in a group of 64 children in Rwanda reported a high ICC
(0.88).[139]
Concurrent validity: The majority of selected studies assessed
the concurrent validity of the WHODAS 2.0. WHODAS 2.0 scores
were correlated with other self-reported measures of lived health
(functional health, well-being, and quality of life), such as the
World Health Organization Quality of Life.[79, 98, 99, 120, 137, 138,
160,162,210,217,218,220,229,245,250,264,293,294,317,358,388,405,
411,412,433,467,511,528,569,636,637,642,645,655,675,676,679,686,
687,724,742–744,747,762,805,821,825] and the Short-Form Health
Survey [76,77,91,97,108,125,130,134,146,165,196,205,206,219,230,
271,309,340,364,366,380,381,415,444,513,527,538,539,572,575,577,
584,591,593,596,604,641,645,650,658,702,725,736,745,749,754–756,
761, 764–766, 773, 792, 797, 810, 815, 816, 835, 844] Results reported
inverted correlations (as the level of disability increases, the
lived health decreases) ranging from moderate (0.41 to 0.58)
to strong (0.60 to 0.70). Three studies [591,761,821] that per-
formed item to item correlations also found weak scores (0.27
to 0.38). WHODAS 2.0 was also correlated with disease-specific
measures, among persons with arthritis [754]; depression [93,219,
497]; back pain [219, 666]; ankylosing spondylitis [797]; HIV/
AIDS [300]; schizophrenia [242, 338]; acquired hearing loss [125];
systemic sclerosis [764,765]; vestibular disorders [801]; anxiety [94,
257]; post-traumatic stress disorder [165]; acute myocardial infarc-
tion [812]; personality disorders [85]; generic severe mental illness
[174, 175]; in rehabilitation patients [130, 627]; in general popula-
tion samples in diverse countries and cultures [509, 671]; and in
users of mental health services.[411] The reported correlations
were moderate (0.40 to 0.49) to strong (0.50 or greater).
Discussion
We investigated use of WHODAS 2.0 in international scientific
literature from 1999 to 2015. Data on the version, language,
and psychometric properties of WHODAS 2.0 were analyzed as
well as the countries and research fields in which it has been
used, and the purpose, design and results of the studies that
used it.
The growing number of studies that employed WHODAS 2.0
for health research may have been influenced by the DSM-5 indi-
cation. Nevertheless, the proportion of studies reporting on the
use of WHODAS 2.0 in psychiatry remained unchanged over the
years. This suggests that the increasing interest in use of the tool
extends to all the life sciences rather than being limited to psych-
iatry. This bolsters the argument that the tool is suitable for
assessing health status and disability in a variety of settings and
populations.[25,26,114]
The cross-cultural viability of the instrument [25] is demon-
strated by the fact that by the end of 2015 it had been adminis-
tered in almost 100 countries and almost 50 languages and
dialects.
Although there is interest in WHODAS 2.0 across the life scien-
ces, its origins in psychiatry [23] are evident in the over-represen-
tation of psychiatric studies (40%) in research using the
instrument; no other field accounts for as much as 15% of
research (e.g., geriatrics: 14,9%, neurology, disability and rehabili-
tation: 9%, health sciences: 6%, epidemiology: 4%).
Almost one in three studies did not provide information on
the version of WHODAS 2.0 used. This prevents us from providing
reliable data on the relative popularity of the different versions.
However, the homogeneous distribution of the use of the two
versions (12-item: 29.5%; 36-item: 30%) allows us to infer a similar
interest in both, probably due to their substantially similar validity
and reliability.
The very poor internal consistency (Cronbach’s alpha 0.50)
for the self-care domain is probably due to floor effects in some
populations. Although the general population might show vari-
ability in functioning with respect to communication, mobility, life
activity, and social participation, it is likely that functioning in the
self-care domain (e.g., activities such as washing one’s body or
getting dressed) is homogenously high.[125,136,662] Moreover, as
Sen [18] demonstrated, the internal view of health and individual
functioning can be misleading, subject to cultural bias. For
instance, the incidence of reported morbidity (self-perception of
health), measured through the administration of self-report ques-
tionnaires, is directly proportional to life expectancy (observational
health).[18] The self-reported limitations in activities might be sen-
sitive to cultural and reporting bias.[846] In some populations, lim-
itations in “washing body” or “getting dressed” might not be
 WHODAS 2.0: AN INTERNATIONAL SYSTEMATIC REVIEW 7

Table 1. Summary of studies that estimated the internal consistency (Cronbach’s alpha) of the WHODAS 2.0 total score.
WHODAS 2.0 version Language Country Population Cronbach’s alpha Study
12-item Chinese China Elderly 65 years 0.97 (urban area) Sousa et al. 2010 [549]
0.91 (rural area)
English USA Huntington’s Disease 0.94 Carlozzi et al. 2015 [571]
Hindi India Elderly 65 years 0.93 (urban area) Sousa et al. 2010 [549]
0.95 (rural area)
Italian Italy Brain tumors Cerebrovascular disease 0.88 Schiavolin et al. 2014 [620]
Spinal diseases
Japanese Japan Elderly mean age 80 From 0.67 to 0.98 a
Tazaki et al. 2014 [137]
Portuguese Portugal Adults 55 years 0.86 Moreira et al. 2015 [519]
Spanish Cuba Elderly 65 years 0.93 Sousa et al. 2010 [549]
Dominican Rep. Elderly 65 years 0.90 Sousa et al. 2010 [549]
Mexico Elderly 65 years 0.92 (urban area) Sousa et al. 2010 [549]
0.93 (rural area)
Peru Elderly 65 years 0.95 (urban area) Sousa et al. 2010 [549]
0.91 (rural area)
Spain Major Depressive Disorder 0.89 Luciano et al. 2010 [324]
Venezuela Elderly 65 years 0.92 Sousa et al. 2010 [549]
36-item – – General Population 0.98 € un et al. 2010 [25]
Ust€
Chinese China Mental disorders 0.93 Wang et al. 2013 [121]
Breast cancer 0.92 Zhao et al. 2013 [799]
Taiwan Physical Disability From 0.91 to 0.98a Chang et al. 2015 [638]
Adults From 0.73 to 0.99a Chiu et al. 2014 [679]
Dutch Netherlands Musculo-skeletal Diseases 0.91 Meesters et al. 2010 [124]
English Australia Spinal Cord Injury 0.95 de Wolf et al. 2012 [577]
USA Hearing Loss 0.94 Chisolm et al. 2005 [125]
French Canada Rheumatoid Arthritis 0.96 Baron et al. 2005 [736]
German Germany Physical disabilities From 0.70 to 0.99a P€osl et al. 2007 [130]
Stroke 0.97 Schlote et al. 2009 [622]
Italian Italy Healthy Adults and adults with Physical From 0.48 to 0.90a and Federici et al. 2009 [136]
Disability mean age  32 from 0.69 to 0.91a
Multiple Sclerosis 0.93 Magistrale et al. 2015 [595]
Japanese Japan Elderly mean age  80 From 0.67 to 0.98a Tazaki et al. 2014 [137]
Malayalam India Lymphatic Filariasis 0.93 Thomas et al. 2014 [144]
Spanish USA Mental disorders 0.95 Ch
avez et al. 2005 [151]
Puerto Rico Mental disorders 0.92 Ch
avez et al. 2005 [151]
Spain Schizophrenia 0.94 Guilera et al. 2012 [269]
Schizophrenia From 0.50 to 0.87a Galindo-Garre et al. 2015
[254]
Bipolar Disorder From 0.73 to 0.92a Guilera et al. 2015 [268]
Turkish Turkey Stroke 0.90 K€uç€
ukdeveci et al. 2013
[769]
Schizophrenia From 0.60 to 0.90a Ulug  et al. 2001 [156]
WMH-WHODAS Arabic Lebanon Mental disorders 0.90 von Korff et al. 2008 [671]
Chinese China Chronic illnesses 0.98 Cheung et al. 2015 [640]
English New Zealand Mental disorders 0.92 von Korff et al. 2008 [671]
Nigeria 0.92
French France 0.92
Belgium 0.90
Hebrew Israel 0.94
Spanish Colombia 0.91
Mexico 0.92
Ukrainian Ukraine 0.93
WHODAS-Child Kinyarwanda Rwanda Children 0.84 Scorza et al. 2013 [139]
a
Cronbach’s alpha was calculated separately for the six domains; we report the maximum and minimum values.

perceived as not a personal limitation, e.g., where people lack
access to water (cultural bias); or when people with high cognitive
impairment have problems prioritizing their tasks and forget some
self-care activities (reporting bias).[846]
The factor structure of the 36-item version of WHODAS 2.0
shows a mild correspondence with the theoretically six-domain
structure. The number of cross loading items could be due to the
partial conceptual overlap between some aspects of the different
domains of WHODAS 2.0.[136]
We agree with von Korff et al. [115] that the strong correlations
(0.50 or greater) between WHODAS 2.0 scores and other measures
of limitations on activity, including disease-specific measures, are
not surprising. Although different scales measure distinct facets of
activity limitation and disability, they generally measure the same
latent global disability variable.
Using a fine-grained methodological approach (non-parametric
item response analysis by means of the Kernel-Smoothing tech-
nique [847]), Luciano et al. [322] indicated that the 12-item ver-
sion was very good at assessing overall disability in patients with
a first-time diagnosis of major depression. More specifically, this
analysis demonstrated that the instrument is unidimensional, dis-
criminates adequately between different levels of disability, that
patients did not have special difficulties in differentiating between
the five response options, and that the 12 items did not show dif-
ferent functioning in terms of gender (overestimation of disability
level in women in comparison to men or vice versa).
Although WHODAS 2.0 seems to be a valid, reliable self-report
instrument for the assessment of disability, a number of the stud-
ies indicate that it has some limitations. For instance, von Korff
et al. [115] noted that although the 36-item version provides a
8 S. FEDERICI ET AL.
supplementary question about employment status (“In the past 30
days, on how many days did you miss work for half a day or
more because of your health condition?”) and the 12-item
includes questions about limitations on daily activities (e.g.,
“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?”), these items are not integrated into subscales or the
total WHODAS 2.0 score. In addition, some WHODAS 2.0 items are
relatively complex and difficult to use in circumstances where the
self-report technique is problematic, i.e., with people who do not
understand the questions, people with dementia or severe cogni-
tive impairment, patients in the acute phase of a psychotic
disorder,[115] and psychiatric patients who have poor insight
into their illness denying having “emotional or mental prob-
lems”.[117,217]
Conclusions and future directions
To sum up, the present work offers a comprehensive literature
review of WHODAS 2.0, the current leading measure of disability
worldwide. Despite some limitations and shortcomings pointed
out in previous reviews,[57] the different WHODAS 2.0 versions
have demonstrated sound psychometric properties irrespective of
the type of population (clinical/non-clinical samples), language, or
country where they have been tested. In our opinion, evidence is
scant regarding some particular aspects of the WHODAS 2.0, such
as its measurement invariance [723] across gender, age groups,
socioeconomic status, culture, etc. A critical issue for healthcare
providers is the “minimal clinically important difference” (MCID)
score for outcome measures. As far as we know, a single MCID
score for the WHODAS 2.0 has not yet been established. Finally,
there is an initiative promoted by the WHO to use the ICD and
ICF in a complementary way in clinical practice, and functioning
properties are being introduced in the ICD-11.[848] Moreover, the
ICD-11 (expected release in 2018) is going to be compatible with
the DSM-5, adopting much of the DSM-5’s structure, adding some
of the new DSM-5 disorders, and by making a separate oper-
ational assessment of disability by means of the ICF-linked assess-
ment tools. Therefore, we suspect that the ICD-11 will likely
encourage the use of the WHODAS 2.0 with even more emphasis
than the DSM-5.
Disclosure statement
The authors report that they have no conflicts of interest.
Funding
The last listed author (J. V. L.) has a “Miguel Servet” research con-
tract from Instituto de Salud Carlos III [CP14/00087] [CP14/00087]
ORCID
Stefano Federici http://orcid.org/0000-0001-5681-0633
Marco Bracalenti http://orcid.org/0000-0002-8768-3793
Fabio Meloni http://orcid.org/0000-0002-4161-9956
Juan V. Luciano http://orcid.org/0000-0003-0750-1599
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