Appendix 2: Questionnaire Used in the Pilot Test in Five Selected Countries

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Statistics Division

Training Manual on Disability Statistics

ESCAP/WHO Project on Health and Disability Statistics

Disability Question Set Testing

Study One: Specificity and Sensitivity Testing
Study Two: Test-Retest Reliability
Study Three: Cognitive Interview

Questionnaire
Version A

May 2005

SECTION 1. Face Sheet

ITEMS F1- F5 ARE TO BE COMPLETED BY INTERVIEWERS PRIOR TO STARTING EACH INTERVIEW

RESPONDENT I.D.#


Centre # -	Subject # -	Interview time point

INTERVIEWER I.D.#


Centre # -	Interviewer #

INTERVIEW TIME POINT (1, 2, ETC.)

a) INTERVIEW DATE

	/		/
month		day		year

b) STARTING TIME

	/
hrs		min

c) TIME INTERVIEW ENDED

	/
hrs		min

d) TOTAL DURATION

	/
hrs		min

LIVING SITUATION AT TIME OF INTERVIEW (CIRCLE ONLY ONE)

Independent in Community		1
Assisted Living		2
Hospitalized		3

SAMPLE (CIRCLE ONLY ONE)

General population		1
Other (specify)		6

SECTION 2. DEMOGRAPHIC AND BACKGROUND INFORMATION

PREAMBLE

SAY TO RESPONDENT:

This interview has been developed by the WHO / ESCAP Project on Health and Disability Statistics 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 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.

RECORD SEX AS OBSERVE

Female	1
Male	2

How old are you now?

___

years

How many years in all did you spend studying in school, college or university?

___

years

What is your current marital status? (SELECT THE SINGLE BEST OPTION)

Never married	1
Currently married	2
Separated	3
Divorced	4
Widowed	5
Cohabiting	6

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

SECTION 3. DISABILITY QUESTION SETS

Question Set 1

The next questions ask about difficulties you may have doing certain activities because of a HEALTH PROBLEM
		No	Some	A lot	Unable
W1	Do you have difficulty seeing, even if wearing glasses?	1	2	3	4
W2	Do you have difficulty hearing, even if using a hearing aid?	1	2	3	4
W3	Do you have difficulty walking or climbing steps?	1	2	3	4
W4	Do you have difficulty remembering or concentrating?	1	2	3	4
W5	Do you have difficulty (with self-care such as) washing all over or dressing?	1	2	3	4
W6	Because of a physical, mental, or emotional health condition, do you have difficulty communicating, (for example understanding or being understood by others)?	1	2	3	4

Question Set 2

Part 1: Introduction

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.)

Part 2: Questions on body functions

I am going to ask some questions about your body functions. Please remember that I am asking only about difficulties you experienced in the last 30 days that are due to health problems. POINT TO FLASHCARDS #1 AND #2
		None	Mild	Moderate	Severe	Extreme / Cannot Do
B1.1	How much of bodily aches or pains did you have?	1	2	3	4	5
B1.2	How much bodily discomfort did you have?	1	2	3	4	5
B1.3	Have you had a problem with a skin defect of face, body, arms or legs?	1	2	3	4	5
B1.4	Have you had a problem with your appearance due to missing or deformed or paralyzed arms, legs, feet?	1	2	3	4	5
B1.5	How much difficulty did you have in using your hands and fingers, such as picking up small objects or opening or closing containers?	1	2	3	4	5
B1.6	How much difficulty did you have in seeing and recognizing a person you know across the road? (take into account eye glasses, if you wear them) Read the brackets if you see respondent wearing glasses.	1	2	3	4	5
B1.7	How much difficulty did you have in seeing and recognizing an object at arm's length or in reading? (take into account eye glasses, if you wear them) Read the brackets if you see respondent wearing glasses.	1	2	3	4	5
B1.8	How much difficulty did you have in hearing someone talking on the other side of the room in a normal voice? (take into account hearing aids, if you use them) Read the brackets if you see respondent using hearing aid..	1	2	3	4	5
B1.9	How much difficulty did you have in hearing what is said in a conversation with one other person in a quiet room? (take into account hearing aids, if you use them) Read the brackets if you see respondent using hearing aid.	1	2	3	4	5
B1.10	How much of a problem did you have passing water (urinating) or in controlling urine (incontinence)?	1	2	3	4	5
B1.11	How much of a problem did you have with defecating, including constipation?	1	2	3	4	5
B1.12	How much difficulty did you have with shortness of breath at rest?	1	2	3	4	5
B1.13	How much difficulty did you have with shortness of breath with mild exercise, such as climbing uphill for 20 meters or stairs (such as 12 steps)?	1	2	3	4	5
B1.14	How much difficulty did you have with coughing or wheezing for ten minutes or more at a time?	1	2	3	4	5
B1.15	How much of the time did you have a problem with sleeping, such as: falling asleep, waking up frequently during the night or waking up too early in the morning?	1	2	3	4	5
B1.16	How much of a problem did you have with feeling sad, low or depressed?	1	2	3	4	5
B1.17	How much of a problem did you have with worry or anxiety?	1	2	3	4	5

Part 3: Questions on Activities and Participation

DOMAIN 1 Understanding and Communicating

I am going to ask some questions about understanding and communicating. Please remember that I am asking only about difficulties you experienced in the last 30 days that are due to health problems. POINT TO FLASHCARDS #1 AND #2
		None	Mild	Moderate	Severe	Extreme / Cannot Do
D1.1	How much difficulty did you have in concentrating on doing something for ten minutes?	1	2	3	4	5
D1.2	How much difficulty did you have in remembering to do important things?	1	2	3	4	5
D1.3	How much difficulty did you have in analysing and finding solutions to problems in day to day life?	1	2	3	4	5
D1.4	How much difficulty did you have in learning a new task, for example, learning how to get to a new place?	1	2	3	4	5
D1.5	How much difficulty did you have in generally understanding what people say?	1	2	3	4	5
D1.6	How much difficulty did you have in starting and maintaining a conversation?	1	2	3	4	5

DOMAIN 2 Getting Around

I am now going to ask you about difficulties in getting around. Please remember that I am asking only about difficulties you experienced in the last 30 days that are due to health problems. POINT TO FLASHCARDS #1 AND #2
		None	Mild	Moderate	Severe	Extreme / Cannot Do
D2.1	How much difficulty did you have in standing for long periods such as 30 minutes?	1	2	3	4	5
D2.2	How much difficulty did you have in standing up from sitting down?	1	2	3	4	5
D2.3	How much difficulty did you have in moving around inside your home?	1	2	3	4	5
D2.4	How much difficulty did you have in getting out of your home?	1	2	3	4	5
D2.5	How much difficulty did you have in walking a long distance such as a kilometre [or equivalent]?	1	2	3	4	5

DOMAIN 3 Self Care

I am now going to ask you about difficulties in taking care of yourself. Please remember that I am asking only about difficulties you experienced in the last 30 days that are due to health problems. POINT TO FLASHCARDS #1 AND #2
		None	Mild	Moderate	Severe	Extreme / Cannot Do
D3.1	How much difficulty did you have in washing your whole body?	1	2	3	4	5
D3.2	How much difficulty did you have in getting dressed?	1	2	3	4	5
D3.3	How much difficulty did you have in eating?	1	2	3	4	5
D3.4	How much difficulty did you have in staying by yourself for a few days?	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 you experienced in the last 30 days that are due to health problems. POINT TO FLASHCARDS #1 AND #2
		None	Mild	Moderate	Severe	Extreme / Cannot Do
D4.1	How much difficulty did you have in dealing with people you do not know?	1	2	3	4	5
D4.2	How much difficulty did you have in maintaining a friendship?	1	2	3	4	5
D4.3	How much difficulty did you have in getting along with people who are close to you?	1	2	3	4	5
D4.4	How much difficulty did you have in making new friends?	1	2	3	4	5
D4.5	How much difficulty did you have in sexual activities?	1	2	3	4	5

DOMAIN 5 Life Activities

I am now going to ask you about difficulties involved in household and work or school related activities. Please remember that I am asking only about difficulties you experienced in the last 30 days that are due to health problems. POINT TO FLASHCARDS #1 AND #2
		None	Mild	Moderate	Severe	Extreme / Cannot Do
D5.1	How much difficulty did you have in taking care of your household responsibilities?	1	2	3	4	5
D5.2	Doing your most important household tasks well?	1	2	3	4	5
D5.3	How much difficulty did you have in getting all the household work done that you needed to do?	1	2	3	4	5
D5.4	How much difficulty did you have in getting your household work done as quickly as needed?	1	2	3	4	5
D5.5	How much difficulty did you have in your day to day work/school?	1	2	3	4	5
D5.6	How much difficulty did you have in doing your most important work/school tasks well?	1	2	3	4	5
D5.7	How much difficulty did you have in getting all the work done that you need to do?	1	2	3	4	5
D5.8	How much difficulty did you have in getting your work done as quickly as needed?	1	2	3	4	5

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.
		None	Mild	Moderate	Severe	Extreme / Cannot Do
D6.1	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
D6.2	How much of a problem did you have because of barriers or hindrances in the world around you?	1	2	3	4	5
D6.3	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
D6.7	How much of a problem did your family have because of your health problems?	1	2	3	4	5
D6.8	How much of a problem did you have in doing things by yourself for relaxation or pleasure?	1	2	3	4	5

Part 4: Questions on need for assistance

I am going to ask some questions about your need for assistance.

No Yes, sometimes Yes, always

E1 Do you ever need someone to help with, or be with you for, self care activities?
For example: doing everyday activities such as eating, showering, dressing or toileting. 1 2 3

E2 Do you ever need someone to help with, or be with you for, body movement activities?
For example: getting out of bed, moving around at home or at places away from home. 1 2 3

E3 Do you ever need someone to help with, or be with you for, communication activities?
For example: understanding, or being understood by, others. 1 2 3

E4 What are the reasons for the need for assistance or supervisions shown in questions 1, 2, and 3?
(Mark all applicable reasons)

a) No need for help or supervision

b) Short-term health condition (lasting less than six months)

c) Long-term health condition (lasting six months or more)

d) Disability (lasting six months or more)

e) Old or young age

f) Difficulty with English language

g) Other cause