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Validation of the WHO-5 as a screening tool for depression among young

adults in Malaysia

Article  in  Current Psychology · August 2021

DOI: 10.1007/s12144-021-02152-1

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VALIDATION OF THE WHO-5 1

Validation of the WHO-5 as a Screening Tool for Depression among Young Adults in

Malaysia

Kah-Yue Low, Kai-Shuen Pheh, and Chee-Seng Tan

Department of Psychology and Counselling, Faculty of Arts and Social Science,

Universiti Tunku Abdul Rahman (UTAR), Kampar, Malaysia

Author Note

Kah-Yue Low https://orcid.org/0000-0002-5133-4137

Kai-Shuen Pheh https://orcid.org/0000-0003-2371-9053

Chee-Seng Tan https://orcid.org/0000-0003-2474-6942

Correspondence concerning this article should be addressed to Kai-Shuen Pheh

(email: phehks@utar.edu.my), PF-011, FAS, UTAR, Jalan Universiti, Bandar Barat, 31900

Kampar, Perak D.R., Malaysia. Phone number: (+6)05-4688888 (Ext: 2521).

Note on the copyright:

This is the accepted version of the following article:
Low, K.-H., Pheh, K.-S., & Tan, C.-S. (2021). Validation of the WHO-5 as a screening tool
for depression among young adults in Malaysia. Current Psychology. Advance online
publication. https://doi.org/10.1007/s12144-021-02152-1

The above article is available at

https://link.springer.com/article/10.1007%2Fs12144-021-02152-1

This accepted version of the article may vary to the finally published version. Use this
material for personal use only. Permission from Springer must be obtained for all other uses.
VALIDATION OF THE WHO-5 2

Declarations

Funding: The authors did not receive support from any organization for the submitted work.

Conflict of interest: The authors have no conflicts of interest to declare that are relevant to

the content of this article.

Ethical approval: All procedures followed were in accordance with the ethical standards of

the responsible committee on human experimentation (institutional and national) and with the

Helsinki Declaration of 1975, as revised in 2000 (5). The project was reviewed and approved

by the Scientific and and Ethical Review Committee of Universiti Tunku Abdul Rahman (Ref

no: U/SERC/176/2020)

Consent to participate: Informed consent was obtained from all individual participants

included in the study.

Data availability: The datasets generated during and/or analyzed during the current study are

available from the corresponding author on request.

Author contributions: All authors contributed to the study conception and design. Material

preparation, data collection and analysis were performed by all authors. The draft of the

manuscript was written by Kah-Yue Low and Kai-Shuen Pheh, and Chee-Seng Tan

commented on previous versions of the manuscript. All authors read and approved the final

manuscript.
VALIDATION OF THE WHO-5 3

Abstract

As depression has become a major disease burden in Malaysia, an easy-to-use tool with good

psychometric qualities is urgently needed to facilitate the screening process. The current

study aimed to investigate the psychometric qualities of the 5-item World Health

Organization Well-being Index (WHO-5) and the optimal cut-off point for depression

screening in the Malaysian context. A total of 610 undergraduate students answered an online

survey consisting of the English version of the WHO-5 and Patient Health Questionnaire-9

(PHQ-9). Results of confirmatory factor analysis supported the single-factor model. The

present study found the WHO-5 had a good reliability and concurrent validity. Moreover,

receiver operating characteristic analysis indicated that ≤ 13 was the optimal threshold with

acceptable sensitivity and specificity to detect depression. This study concludes the WHO-5

is a brief, valid, and reliable depression screening tool among young adults in Malaysia.

Keywords: confirmatory factor analysis, optimal cut-off, reliability, validity, World

Health Organization Well-being Index, WHO-5

VALIDATION OF THE WHO-5 4

Validation of the WHO-5 as a Screening Tool for Depression among Young Adults in

Malaysia

Depression has become a significant public health problem globally (Herrman et al.,

2019). In Malaysia, depression has affected 2.3% of the adult population and has become the

major cause of disease burden (Institute for Public Health, 2020). Often, depression is a result

of complex interaction of biological, psychological and social factors (Serafini et al., 2016;

Serafini et al., 2017). Therefore, a psychometrically sound screening tool is urgently needed

for depression research and intervention. While a number of depression screening instruments

(Rusli et al., 2017; Sherina et al., 2012) are available, most of them acquired negative phrased

items that ask explicitly for depressive symptoms. Those items may be underreported due to

the shame and self-stigma associated with psychic disorder when admitting dysfunction in

oneself (Sisask et al., 2008), particularly in Asian culture (Yang et al., 2020). The World

Health Organization Well-being Index (WHO-5; World Health Organization, 1988) is a

positively-phrased measure of subjective well-being and has also been widely used for

depression screening (Topp et al., 2015). Although the WHO-5 has been validated in

different countries, the psychometric properties and cut-off point of the scale have not been

established in Malaysia. This study aimed to investigate the factorial structure, validity,

reliability, and the optimal cut-off point of the WHO-5 as a brief depression screening tool in

Malaysia. The results are expected to recommend the cut-off point for depression screening

among young adults in Malaysia and verify the usability of the WHO-5 in cross-cultural

studies.

Method

Design, Participants, and Procedures

Cross-sectional design and convenience sampling were employed to recruit 615

undergraduate students. The inclusion criteria for participants in this study were (a)
VALIDATION OF THE WHO-5 5

undergraduate students aged between 18 to 35 years old; (b) English-literate; (c) have access

to the internet. Five participants who answered less than 50% of the items were excluded.

Among the 610 respondents (Mage = 21.806, SD = 2.112; range = 18 to 35), 76.9% were

female. The majority of them (84.9%) were Chinese, followed by Malays (7.4%), Indians

(6.6%), and other ethnicities (1.2%). Respondents were students from different years of

study, including Year 1 (19.0%), Year 2 (33.6%), Year 3 (34.9%), Year 4 and above (12.3%),

and one as unidentified. Data were collected through social media (e.g., Facebook) from

January to March 2021. Ethical approval was obtained from the university (ref. no: [masked

for review]). Data was analysed using JASP.

Measurements

As English is the medium of instruction in most of the universities in Malaysia, the

study employed the original English version of the following scales.

World Health Organization Well-being Index (WHO-5; World Health Organization, 1988)

The WHO-5 is a brief, self-reported scale with five items that are positively worded

that measures people’s current level of subjective well-being in the past two weeks. Items are

rated on a 6-point Likert scale (0: At no time; 5: All of the time). The raw score ranges from 0

to 25, which higher scores indicate better mental well-being. Generally, scores below 13 may

indicate poor well-being. The WHO-5 has portrayed good psychometric properties (i.e.

validity and internal consistency) across numerous validation studies (e.g. Cichoń et al.,

2020). Past studies have suggested satisfactory results when the WHO-5 was used for

depression screening (e.g. Guðmundsdóttir et al., 2014). In a systematic review, the

sensitivity and specificity of the WHO-5 as depression screening tool were .86 and .81

respectively (Topp et al., 2015).

Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001)

VALIDATION OF THE WHO-5 6

PHQ-9 is a 9-item measure for the severity of depressive symptoms in the past two

weeks. Items in the PHQ-9 represent the nine criteria stated in Diagnostic and Statistical

Manual of Mental Disorders, Fifth Edition (DSM-V) for diagnosing major depressive

disorder. Items are rated on a 4-point Likert scale (0: not at all; 3: nearly every day). The

overall sensitivity and specificity of the PHQ-9 ranged from 0.37 to 0.98 and 0.42 to 0.99

respectively in a systematic review (Costantini et al., 2021). PHQ-9 showed a sensitivity

of .87 and specificity of .82 in the Malaysian context (Sherina et al., 2012). Total score of the

PHQ-9 ranges from 0 to 27. In this study, PHQ-9 yielded a good internal consistency

(Cronbach’s alpha [⍺] = .869) and a score of ≥ 10 indicated a current depressive episode.

Analytical Approach

Confirmatory factor analysis (CFA) was employed to verify the factorial structure of

the WHO-5 using the following suggested cut-off values: comparative fit index (CFI),

Tucker–Lewis index (TLI), and goodness of fit (GFI) value ≥ .95; root-mean-square error of

approximation (RMSEA) < .06; and standardized root-mean-square residual (SRMR) < .08

(Hu & Bentler, 1999).

Reliability was examined using ⍺ coefficient, while the concurrent validity of the

WHO-5 was examined by correlating with the scores of PHQ-9 using Pearson’s correlation.

Moreover, receiver operating characteristic (ROC) analysis was conducted against PHQ-9

scores to examine the optimal cut-off point for the WHO-5. Sensitivity, specificity, positive

predictive value (PPV), and negative predictive value (NPV) were calculated to examine the

diagnostic accuracy for the WHO-5.

Results

Confirmatory Factor Analysis (CFA)

The one-factor model showed good fit: χ² (5) = 36.593, p < .001, CFI = .982, TLI

= .963, GFI = .977, RMSEA = .102, and SRMR = .023. As RMSEA > .08, we referred to
VALIDATION OF THE WHO-5 7

modification indices and added an error covariance between items 1 and 4. The modified

model showed excellent fit: χ² (5) = 11.463, p = .022, CFI = .996, TLI = .989, GFI = .993,

RMSEA = .055, and SRMR = .014, suggesting that the WHO-5 is a single-factor construct.

All (standardized) factor loadings were statistically significant and greater than .90.

Reliability and Validity

The WHO-5 showed good internal consistency (⍺ = .896), implying that the items are

conceptually relevant with each other. Moreover, the WHO-5 score had a negative correlation

with the PHQ-9 score, r(608) = -.558, p < .001. The results support the concurrent validity of

the WHO-5, indicating that the WHO-5 has moderate agreement with the PHQ-9, a gold-

standard of depression screening.

The Optimal Cut-Off for the WHO-5

Under the cutoff of 12.5 / <13, the area under the ROC curve was .780, sensitivity

= .779 and specificity = .672. The PPV and NPV of the WHO-5 was .670 and .753,

respectively.

Discussion

Our study found good reliability and validity of the WHO-5 among young adults in

Malaysia, with an optimal cut-off point of < 13 for depression screening. Our results provide

empirical evidence of the applicability of the WHO-5 in Malaysia context.

Consistent with past findings from young adults (Ghazisaeedi et al., 2021) and people

with medical conditions (Cichoń et al., 2020; Dadfar et al., 2018; Eser et al., 2019), the CFA

results support the single-factor model. Adding error covariance between items 1 (assessing

general mood; “I have felt cheerful in good spirits”) and 4 (assessing sleep quality; “I woke

up feeling fresh and rested”) improved the model fit. This could be due to a general mood

associated with sleep quality in our sample.

VALIDATION OF THE WHO-5 8

The WHO-5 also showed good reliability and concurrent validity among young adults

in Malaysia. Our finding is similar to those studies conducted with clinical and community

samples (e.g., Halliday et al., 2017; Omani-Samani et al., 2019; Perera et al., 2020).

The present study is the first to suggest the cut-off value of the WHO-5 in the

Malaysian context. Consistent with past studies (e.g., Christensen et al., 2015; Ghazisaeedi et

al., 2021; Halliday et al., 2017), the WHO-5 shows acceptable sensitivity (78%) and

specificity (67%) for the optimal (12.5 / ≤13) cut-off value. The findings highlight the

usefulness of the WHO-5 across cultural contexts.

It is noteworthy that the relatively low specificity may lead to false-positive cases.

Nevertheless, it is acceptable because people who reported low levels of well-being may

suffer from other forms of mental disorders (e.g., anxiety disorders, adjustment disorder) and

a follow-up visit to mental health professionals is typically harmless. Importantly, the NPV

(0.75) is good, indicating the WHO-5 yielded few false-negative results that may result in

unattended mental health problems.

Despite the encouraging results found in the present study, it is important to note that

a few limitations were presented in this study. First of all, the sample was limited to

university students, who have good to excellent English proficiency. Therefore, the findings

may not be fully generalizable to the general population in Malaysia. Since Malaysia is a

multi-ethnic and multilingual country, it is recommended to translate the scale into local

languages (e.g., Malay, Mandarin, and Tamil languages).

Conclusion

This study adds to the growing options of depression screening tools in Malaysia. The

positively worded WHO-5 is a rapid, non-intrusive mental health screening instrument that

can be used by both mental health professionals as well as non-specialized staff to identify
VALIDATION OF THE WHO-5 9

depression among young adults in Malaysia. The freely available, and easy self-administered

questionnaire may be also suitable to be used in large-scale epidemiological studies.

VALIDATION OF THE WHO-5 10

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