The questionnaire has been developed by WHO and ESCAP for testing of disability questions sets for use in census and surveys. The data collected will help to identify the best set of questions that explain the greatest variance in disability with the smallest number of questions. The instrument is intended to be used in different cultures and a variety of settings.

The appendix includes:

Appendix A: Flashcard #1
Appendix B: Flashcard #2

To avoid a response bias due to an order effect, the questionnaire comes in two versions. Version A lists Question Set 1 followed by Question Set 2, Version B starts with Question Set 2 and then proceeds to Question Set 1.

This manual is a training tool for interviewers who will administer the questionnaire.

The questionnaire is to be administered to adults aged 18 or older from different educational and cultural backgrounds. Respondents do not need to be literate, although, depending on age, maturity, cognitive ability, and place of origin, respondents may find some questions or concepts more difficult to understand than others. Cards (i.e. the flashcards found in the Appendix) should be provided to respondents as a memory aid. From the total of all respondents 50% should be interviewed with Version A and the other 50% with Version B of the questionnaire.

The interview is expected to last 40 minutes on average, but may take longer depending on the comprehension and literacy level of the respondent. Respondents who have problems with language, who are less educated, who are very talkative or who have many difficulties because of their health condition may take longer to answer questions.

The respondent should be interviewed in private and no other member of the household should be present. If total privacy is not possible, the respondent may have to be interviewed outside the house.

Two types of question format are used in the questionnaire.

• Matrix questions

These are questions that use a common set of answer categories. These questions are asked to obtain information about degrees of difficulties, frequency or related qualities.

D1.1. How much difficulty did you have in concentrating or doing something for 10 minutes?

W1. Do you have difficulty seeing, even if wearing glasses?

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.

• Multiple-choice questions

In this type of question, the respondent is asked to choose one from several options.

A4. What is your current marital status?

Standardization means that every interviewer must conduct the interview the same way with each respondent. This is done to minimize differences in responses that might occur if formatting conventions or interviewing techniques changed with every respondent. A respondent might answer very differently if he was to be interviewed with other people in the room or if the interviewer was unpleasant or patronizing. Likewise, a rushed interview or the interviewer's lack of interest may greatly affect responses. Research has shown that the interviewer can have an effect on the data collection because of four factors: socioeconomic background, unconventional administration of the questionnaire, wording and intonation, and reaction to respondent's difficulties in understanding the questionnaire. Except for the interviewer's background, the other three factors can be addressed in training.

The interviewer is responsible for asking questions, answering the respondent's queries, recording answers and editing the questionnaire. He must check that the respondent has understood the questions by using interviewing techniques, such as neutral probes, clarification and appropriate feedback, and determine whether the answer given is appropriate. Listening to what the respondent is communicating, both verbally and non-verbally, will ensure that the information is correct. The interviewer must set the pace of the interview and keep the respondent focused and interested. The atmosphere should be comfortable and pleasant at all times.

Before going to the field, the interviewer must know the questionnaire and how it is to be administered. A thorough preparation as well as extensive practice will guarantee that this is achieved.

The role of the respondent is to cooperate with the interviewer and follow his instructions. He must listen to questions attentively without interrupting, take his time before answering, and try to give an accurate and complete response as much as possible. The respondent should ask for clarifications whenever a question seems unclear to him and ask the interviewer to repeat or rephrase it. Trying to answer an unclear question is likely to lead to an incorrect response.

The role of the supervisor is to check that interviewers perform their work well. This includes handling the logistics of the survey, coordinating with other staff, recruiting and training additional interviewers, and supervision. Supervision must be given to interviewers before, during, and after the interview. Supervisors must not only check that contact procedures are followed correctly but that interviews are conducted appropriately. They should be present for 10 interviews and ensure that standardized interviewing techniques are observed when asking questions, clarifying, probing and giving feedback in a non-directive manner. After the interview has been conducted, they must also check that data is coded and entered correctly. Supervisors must give feedback and debrief on a regular basis, in order to update the organization responsible for the study on the progress of the survey and any problems that have arisen.

• Anything written in standard print is to be read to the respondent.

Example:

The first questions are about your overall health, including both your physical health and your mental health.

• Anything written in italics and in bold (uppercase or lowercase) is an interviewer instruction and should not be read aloud

Example:

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.

• Words which are underlined within questions are key words or phrases that need to be emphasized when read to the respondent.

Example:

D2.3 How much difficulty did you have in moving around inside your home?

• A line beside the question indicates where the response must be recorded.

Example:

• An option which contains a line is meant to be filled in.

• Items in parentheses () contain examples to illustrate a point and are to be read to the respondent.

Example:

W6. Because of a physical, mental, or emotional health condition, do you have difficulty communicating, (for example understanding or being understood by others)?

• Items in brackets [ ] contain:

Instructions to translators. English-speaking interviewers may also use these guidelines, whenever needed, to clarify a question and/or make it relevant to the respondent's culture.

Example:

D2.5. How much difficulty did you have in walking a long distance such as a kilometre [or equivalent]?

• The function of visual aids is to help respondents remember important information while answering questions and rate different items.

Visual aids are cards that describe terms (e.g. difficulties, health condition etc.) and illustrate scales (e.g. severity response scale)

Enough time must be allowed for the respondent to examine the cards.

Interviewer instructions are given throughout the questionnaire so the interviewer knows when to produce the visual aids and how to use them. Practice is recommended beforehand in order to facilitate the flow of the interview.

The interviewer must clearly communicate the objectives of the survey to the respondent. Knowing what is expected of the respondent will contribute to the accuracy in responses. The interviewer should establish a good rapport by introducing himself and the survey clearly and completely.

• Make a good impression

1. You are a professional interviewer from a legitimate and reputable organization.
2. The questionnaire is for gathering data for important, worthwhile research.
3. The respondent's participation is vital to the success of the research.
4. The responses given will be confidential and will only be used for research purposes.

The interviewer might used the following introduction (or find something that works better):

"Hello my name is.and I work for.. The reason I am contacting you is because we are conducting a study on health in our country and I would like to ask you a few questions. Let me assure you that whatever information you tell us will not be disclosed to anyone and will only be used for research purposes."

• Conduct the interview clearly and pleasantly

1. You should be pleasant and assertive, and make the respondent feel at ease.
2. You should know the questionnaire thoroughly and be well prepared to answer any questions.
3. You should speak slowly and clearly to set the tone for the interview.
4. You should adapt your introduction to the respondent, as different respondents require different amounts of information.
5. You should be motivated and interested in the interview.

When asking questions, the interviewer should point out that there are no right or wrong answers and that the interview is not a test. There are rules in interviewing that should be followed to avoid biased answers and to ensure comparability of data.

Options must be read aloud to the respondent, except for Don't know (DK), Refuse, Not Applicable (NA) and other.

• Read questions as they are written in the text and do not change the wording (paraphrase or rephrase).
• Do not change the order of the questions.
• Read the questions slowly and clearly, emphasizing key words. The pace should be about two words per second.
• Read the questions in a pleasant voice that conveys interest, assurance and professionalism.
• Maintain eye contact or whatever is culturally appropriate.
• Read the entire question to the respondent making sure that he has heard all of it. If respondent interrupts before the end, the question should be repeated.
• Do not skip questions even if the respondent has given the answer earlier or if one answer applies to questions that are similar, unless you are certain of the answer.
• Verify information volunteered by respondent. The respondent may volunteer information before a question is asked. If the interviewer asks that question when it comes up and ignores what the respondent has said earlier, he may be annoyed because he thinks that the interviewer was not listening to him.

A. Ask questions with a preface to acknowledge the fact that the respondent has already provided information relevant to a particular question. The interviewer may read the question with a preface.

"You told me that before.but I still need to ask you this question as it is written".

B. Skip questions only if the interviewer knows with certainty that a question has already been answered. This is not recommended.

• Use lead-in statements, such as "how much difficulty did you have in." to help the respondent answer the question and keep the interview moving.

The interviewer should not assume what the respondent will say, or think, because of health condition or lifestyle, that the respondent is bound to answer one way rather than another. The interviewer may be tempted to skip questions because or make comments such as "I know this probably doesn't apply to you, but..." This practice may prevent getting accurate and unbiased information or learn to what extent answers to earlier questions actually do predict answers to later ones.

The interview should not be rushed and the respondent must be allowed enough time to understand and answer a question. If the respondent feels pressured to give a quick reply, he may answer anything that crosses his mind or say that he "doesn't know". In addition, trying to have a rushed interview will slow things down, as questions will need to be repeated a second time.

Clarification is needed when the respondent is unable to answer a question because he does not understand it completely or at all.

When to clarify:

• Whenever the respondent does not seem to understand the question and gives an inappropriate reply.
• When the respondent does not seem to have heard the question.
• When the respondent takes a lot of time to think about his answer.
• When the respondent asks about a specific part of the question. In this case it is acceptable to repeat only that part.

When the respondent asks for one option to be repeated, all the options should be read again. Assumptions should not be made about how the respondent is going to respond. An option may be omitted if the respondent has clearly eliminated it.

When the respondent asks for one term to be clarified, the interviewer should refer to the Question by Question Specifications (see Section III). If the definition does not exist, he should ask the respondent to answer the question according to whatever the question means to him.

Probing is needed when the respondent seems to understand the question but gives a response which does not meet the objectives of the question. It is mainly used to encourage the respondent to expand on what has been said or to clarify his response, while keeping him focused to avoid incomplete answers or irrelevant information.

When to probe:

• The respondent does not seem to understand what is asked, misinterprets the question, cannot make up his mind, or digresses from the topic.
• The respondent seems to have understood the question but has not answered appropriately.
• The respondent has replied correctly but may have other things to say. Silence may be the best probe and will give him time to think and expand on his answer. A look or a nod may also encourage communication.
• The respondent has not given a complete answer or his answer is unclear.
• The respondent needs to give more information.

Probing techniques

• Just repeat the question. The respondent may come up with the right answer if he hears the question a second time.
• Pause. This gives the respondent time to collect his thoughts and expand on his answer if he has more to say. The interviewer must be sensitive enough to know when to use a pause and for how long. Usually a pause together with an expectant look or a nod will encourage communication.
• Repeat the respondent's reply. This is often a very effective way of having the respondent reflect of the answer he has just given. The interviewer can repeat the question as he is recording it.
• Use neutral introductions to avoid biasing responses. Do not ask leading questions or suggest answers such as "I guess you mean.", as they may influence the respondent. Instead say: overall, generally speaking..The interviewer should never give the impression that he approves or disapproves what the respondent says, or that his answer is right or wrong. If the respondent asks for his opinion, the interviewer should say that he is interested in what the respondent has to say and that he needs to keep the interview going. (See Table 1.)

Common probing situations

• Don't know (DK)

When the respondent says "I don't know" to a question, the general rule is to repeat the question. If the respondent still does not know, the interviewer should probe once before recording (DK). An effort at recall should be encouraged with a probe such as:

Could you give me your best estimate?
Which would be closer?

If there is no DK option, DK should be recorded in the right margin.

If after probing the answer is still "don't know", it may mean that the respondent:

• Does not understand the question but is afraid of saying it
• Is taking time to think and wants to gain time
• Does not want to answer because of personal reasons

• Not applicable (NA)

Occasionally, the interviewer may ask a question that the respondent feels does not apply to him. The interviewer should ask him why he thinks this, and write down NA if it is clear that the question is irrelevant. If this option is not available, it should be recorded in the right margin.

In order for probing to be successful, the interviewer must be able to see why the respondent's response is inadequate and does not answer what is asked. To avoid hurting the respondent's feelings when he has been unclear, the interviewer should mention that perhaps he has misunderstood him.

It is important that the interviewer tells the respondent when he/she is doing well. It is also a way of maintaining control over the interview. This will keep the motivation going and encourage good performance. Acceptable performance includes the following:

• Listening to the whole question without interrupting.
• Giving appropriate and complete answers to the questions.
• Answering in a way that meets the objectives of the questions.
• Avoiding digression.

Rule for giving feedback

•  Feedback should be used to keep the respondent focused, discourage digression or inappropriate enquiries.

• Positive feedback must be given for good performance and not good content.
• Feedback can be verbal as well as non-verbal, such as a smile or a nod.
• Short feedback sentences should be used for short responses and longer feedback sentences for longer responses.
• There should be a brief pause after feedback for more effect.
• Vary the type of feedback by using different phrases.
• Certain comments such as "let me make a note of this" can motivate the respondent if he feels that what he is saying is important.

Feedback must always be neutral and the interviewer should acknowledge the respondent's performance by using the following feedback sentences:

Short feedback: to acknowledge responses to close-ended questions

Thank you/Thanks
I see
All right

Long feedback: to reinforce respondent motivation and attention on long series of questions, open-ended questions, or questions that are difficult for the respondent.

That is certainly useful/helpful information.
It is useful to get your ideas on this.
I see, that's helpful to know.
That can be difficult to remember/answer.

Task-related phrases: to acknowledge that what the respondent has said is important and worth recording.

Let me get that down.
Let me make sure I have got that right (repeat answer).
Let me go over what you have just told me.

In addition to listening to what the respondent is saying, it is useful to pay attention to the gestures and tone of voice, as they can often give a better indication of what the respondent is trying to say if his verbal answer is confusing or inarticulate. Anger or frustration may not come through verbally but may be communicated non-verbally.

Situations requiring feedback

• Respondent makes inappropriate enquiries and asks for advice or information, or wants to know about the interviewer's personal experiences.

Suggested phrases:

In this interview, we are really interested in learning about your experiences.
When we finish, let us talk about that.
We will come to that later.

• Respondent digresses from the questions by giving lengthy responses or unnecessary information.

I have many more questions to ask so we should really move on.
If you would like to talk more about that, perhaps we can do it at the end of the interview.

• Respondent gives inappropriate responses or feels like conversing. Silence can be quite effective in this case.

Rules for data entry

The questions must not only be asked correctly but also recorded correctly in order to have unbiased and reliable data. The respondent's answers must all be noted down. It is important to record not only what the respondent said, but also how he said it to be able to recreate the atmosphere of the interview and get an idea of the respondent's personality. A number of things can be done to achieve this:

A. Write down the responses during the interview

• Responses must be transcribed while the respondent is talking, as the interviewer might not remember exactly what was originally said at a later stage.

B. Report what is said, the way it is said (verbatim reporting)

• To preserve the flavour of each interview, responses must be recorded word-for-word, with no attempt to correct grammar, or alter phrases or expressions.
• Responses must not be summarized or paraphrased as data may be misreported or missed out. The length of the response, the words, examples and expressions used by the respondent, all provide valuable information.
• Anything that is related to the question should be noted even if the answer is long. Qualifications such as "if" and "but" should be especially recorded, as well as expressions showing intensity of feelings e.g. "very", "a little".
• Hesitations, mumbling or irrelevant feedback should not be recorded.
• Comments or explanations must be recorded in brackets in the questionnaire next to the corresponding question.
• Keep the respondent's interest. If the interviewer is too absorbed recording the answers the respondent may get bored. It is useful to say the respondent's response aloud as the interviewer writes it down. This will allow the respondent to modify his reply or expand on it once he hears it.

Tips for taking notes

• It is important to find a comfortable place for writing. The interviewer should sit in front of the respondent or in a place where what he writes cannot be seen.
• As soon as the respondent starts talking, the interviewer should start writing in order to reduce the waiting time for the next question.

Techniques for data entry

• Use a pencil for writing. It will be easier to erase any information from the questionnaire or rewrite words or sentences. The interviewer should not erase any notes made, as they can be useful. Red ink is not to be used as it is for editor's corrections.
• The information must be legible. Illegible handwriting is not of much use if only the interviewer can read it.
• Check that all the questions have been asked. If a question has been skipped by mistake, it can be corrected. If the respondent decides to change his mind on one of the options, the new answer must then be recorded.
• Each interview must be identified and the following information must be noted on each questionnaire: interviewer's name, project number, sample ID, interview number, and date of interview.

How to record data

A. Closed-ended questions

When a question requires that one option be circled, the interviewer must neatly circle one number and make sure that no other number is. If an incorrect answer is circled because the respondent has changed his mind or because the interviewer has made a mistake, the answer should be crossed out with a (/) over it, and the correct option circled.

B. Open-ended questions

These questions should be filled in capital letters.

C. Fill-in questions

If entering a number, answer should be "right justified" such as AGE ___/___.

D. Marginal notes

When the respondent gives an option, as well as additional descriptions such as "if", "except" or "but", such qualifications should be recorded in the right margin since they may give important information to the researchers.

E. Uncertainty about the respondent's answer

If the interviewer is uncertain about a respondent's answer, the question should be repeated and the answer recorded exactly (but remember that paraphrasing a response when in doubt is not permitted). If the interviewer understands the response but is not sure about the coding, he should record enough information in the left margin for the coder to decide what it should be. He should also use a question mark (?) in the left margin to indicate the uncertainty to the editor.

If a question does not apply to a respondent and "NA" is not an option in the questionnaire, "NA" will then be recorded on the left margin and entered in the data entry program. Most questions will have "NA" in the program. The same thing will be done for the response "DK". If after probing, the respondent is unable to give an answer, "DK" should be recorded and later entered in the program.

F. Missing data

If the interviewer accidentally misses any question, the interviewer enters MISSED in the right margin of the form. This indicates to the coder that the question was not asked. During an interview, if an interviewer notices that he missed a question, he should go back and ask the question, making a note in the margin that the question was asked out of sequence. If the missing data is not discovered until after the interview, the researcher must re-contact the respondent.

Refusals to answer questions should always be recorded. The interviewer should write "Refuse". Before accepting a refusal, the interviewer should explain the objective of the question to the respondent.

Before leaving the household, the interviewer should review the questionnaire to check that it is complete and that no questions have been omitted. Right after the interview, the interviewer should spend time checking the questionnaire to ensure that:

• All the questions have been answered.
• The information recorded is clear and legible for others to read.
• Comments are indicated by putting them between slashes.
• Open-ended questions are written in full sentences and not in abbreviations.
• The Interviewer Observations and Report is completed.

The interviewer should also edit the coversheet and check that:

• There is no missing information, such as interviewer's name, interview number, date, length of interview and length of editing.
• The address is correct on the sample label.
• Every attempt call to the household is recorded, as well as the re-contact information.

The interviewer should submit the completed form to the study supervisor promptly, so that any errors in administration can be noted and procedures corrected before other interviews are completed incorrectly.

This purpose of this section is to indicate what is intended by each question in the WHO/ESCAP Questionnaire for Disability Question Set Testing. Interviewers should use this information when respondents request clarification about specific questions and should refrain from offering their own interpretations.

Each section is listed alphabetically based on the letter that precedes the number of the question.

SECTION 1. FACE SHEET

QUESTIONS F1 - F6

This section should be completed by the interviewer.

F1. Respondent I.D.

The Centre # is the three-digit number assigned by the study or project coordinator. If you have forgotten your centre number, please contact your study or project coordinator

The Subject # is the unique four-digit number you should assign to that respondent. It is imperative that the number assigned to the respondent be recorded exactly the same way for all interviews, to ensure reliability.

The Interview time point indicates whether the interview is the first or second time the respondent has been interviewed. Enter "1" if the respondent is interviewed for the first time (initial interview). Enter "2" if the person is interviewed for the second time (retest interview). The retest should be done by a different interviewer

F2. Interviewer I.D.

Under Centre # enter the three digit number that identifies your center. Under Interviewer I.D. # enter the three digit number that identifies the interviewer.

F3. Interview Time Point

Indicate whether the interview is the first or second time the respondent has been interviewed. Enter "1" if the respondent is interviewed for the first time (initial interview). Enter "2" if the person is interviewed for the second time (retest interview). The retest should be done by a different interviewer. Check entry on the last box of F1.

F4. Interview date, starting time, time interview ended and total duration

Enter the date the interview took place. Write Month/Day/Year, and fill in the blanks with zeros. For example, February 4, 2004 would be written as 02/04/04. Record when the interview begins and ended and calculate the duration of the interview.

F5. Living situation at the time of the interview

Indicate the type of residence in which the respondent resides.

"Independent in Community" means the respondent lives on his/her own, with family, or friends in the community.

"Assisted Living" refers to a respondent who lives in the community but receives regular assistance with at least some daily activities (e.g., shopping, bathing, meal preparation). This may include physical help, verbal reminders or cues, supervision, or psychosocial assistance. Assistance may be provided from a family member, friend, or professional care.

"Hospitalized" should be indicated if the respondent resides in a 24-hour supervised setting (e.g. nursing home, hospital, rehabilitation facility).

F6. Sample

Sample refers to the primary population category of the respondent:
General population
Other (specify) ______________

Write the name of respondent and circle code 1 if respondent is original or 2 if proxy. Proxy respondents are those who assist the original respondents in communicating directly to the interviewer. Fill in the name of interviewer and the supervisor shall also fill in his/her name and affix respective signature.

SECTION 2. DEMOGRAPHIC AND BACKGROUND INFORMATION

QUESTIONS A1 - A5

Read the preamble first.

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.

Caution: For cases when respondents are obviously not healthy, refrain from mentioning disability and/or difficulties in the preamble to avoid embarrassment on the part of the respondent.

This section should be completed with reference to the person completing the interview.

A1. Record sex as observed

Circle option 1 or 2.

A2. How old are you now?

Record age.

A3. How many years in all did you spend studying in school, college or university?

The term "school" refers to any kind of formal school and excludes short courses (typing, sewing) or religious education such as Bible school or Koran school. It includes technical or vocational training beyond formal school. If a person dropped out of school or university, partial years should not be counted. If someone has been in school both full and part-time, record the number of years at full-time education.

A4. What is your current marital status?

Ask this question without reading the options to the respondent. If the response does not match any of the options e.g. "single", read the options to the respondent and ask him/her to choose the option that best reflects his/her current marital status. For example, if the respondent is currently married (but was divorced in the past), the option "currently married" should be circled.

A5. Which describes your main work status best?

We are interested in the option that best reflects the current main work status. If the respondent gives two options e.g. "homemaker" or "unemployed" ask the respondent to pick the one that best describes their work status.

There is no minimum number of hours per week that a respondent must work to qualify for the paid work category. Similarly, students need not be full time in order to endorse that choice. If the respondent reports being unemployed, interviewers should ask: "is this for health reasons or for other reasons" and record the appropriate option. The option "non-paid (volunteer)" also includes work, which is non-paid, that a person does to help the family. Examples of this kind of work may be farming or helping run the family business.

SECTION 3. DISABILITY QUESTION SETS

QUESTION SET 1

The questions ask about difficulties you may have doing certain activities because of a HEALTH PROBLEM.

Choices of responses should always be mentioned to the respondents. These choices are No, Some, A Lot and Unable.

QUESTIONS W1 - W6

W1. Do you have difficulty seeing, even if wearing glasses?

The purpose of this question is to assess a person's vision taking into account the use of an assistive device.

W2. Do you have difficulty hearing, even if using a hearing aid?

The purpose of this question is to assess a person's hearing taking into account the use of an assistive device.

W3. Do you have difficulty walking or climbing steps?

This question refers to walking or climbing steps at home or outside the home. Any assistive devices or personal help that is usually in place should be taken into account.

W4. Do you have difficulty remembering or concentrating?

The purpose of this question is to assess a person's memory and difficulties in concentration. Any memory or concentration aids (e.g., writing things down, relying on electronic reminder systems) should be taken into consideration when rating this question.

W5. Do you have difficulty (with self-care such as) washing all over or dressing?

This question refers to washing one's entire body, as it is customary for the culture. The question also includes all aspects of dressing the upper and lower body. Any assistive devices or personal help usually in place should be taken into account.

W6. Because of a physical, mental, or emotional health condition, do you have difficulty communicating (for example, understanding or being understood by others)?

The respondent should consider his/her usual mode of communication (e.g. spoken language, sign language, with an assistive device such as a hearing aid) and rate the degree of difficulty in understanding messages of others.

QUESTION SET 2

PART 1. INTRODUCTION

Read the introductory part of this section.

QUESTION SET 2

PART 2: QUESTIONS ON BODY FUNCTIONS B1.1 - B1.17

The respondent is asked to think of the last 30 days. A period of 4 weeks is an optimum period for comparison. Studies have shown that beyond 4 weeks there is a very steep fall in recall.

The notion of difficulty is emphasized and the respondent is asked to describe his condition rather than say how he feels about it.

B1.1. How much of bodily aches or pains did you have?

This refers to any form of pain that interferes with a person's usual activities. By pain we mean "physical" pain for a short or long period of time over any part of the body.

B1.2. How much of bodily discomfort did you have?

This refers to any form of discomfort that interferes with a person's usual activities. By discomfort we mean "physical" low threshold pain for a short or long period of time over any part of the body.

B1.3. How much have you had a problem with a skin defect of face, body, arms or legs?

Problems include pimples, warts, or changes in colour or scarring over large portions of face, body, arms or legs (due to burns, wounds), surgery, skin diseases, skin infections, etc.

B1.4. How much have you had a problem with your appearance for example missing or deformed or paralyzed arms, legs, feet?

The respondent should consider problems he/she has had in living with his/her appearance in the community. Missing, deformed or paralyzed limbs either from birth or due to an accident, a disease.

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?

This includes using hand, fingers and thumb to handle objects, picking up, manipulating and releasing them, such as required to lift coins off a table or turn a dial or knob.

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.

The respondent should answer this question taking into account any assistive device (glasses or contact lenses) she may be using. "Seeing and recognizing a person" under normal circumstances. One would not be expected to recognize a person on a foggy or stormy day for example.

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.

The respondent should answer this question taking into account any assistive device (glasses or contact lenses) he/she may be using.

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.

By "normal" voice we mean not speaking loudly or shouting. Any hearing aid should be taken into account.

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.

This refers to hearing in a quiet room with no background noise. Any hearing aid should be taken into account.

B1.10. How much of a problem did you have passing water (urinating) or in controlling urine (incontinence)?

This includes any problems urinating -- such as urine retention, inability to control urine, increase of the frequency of urinating or feeling pain during urinating.

B1.11. How much of a problem did you have with defecating, including constipation?

This may be diarrhoea as well as constipation.

B1.12. How much difficulty did you have with shortness of breath at rest?

Difficulty in shortness of breath without having done any exercise.

B1.13. How much difficulty did you have with shortness of breath with mild exercise, such as climbing uphill for 20 meters or climbing stairs (such as 12 steps)?

Difficulty in shortness of breath after having done some exercise.

B1.14. How much difficulty did you have with coughing or wheezing for ten minutes or more at a time?

Coughing or wheezing, without having done any exercise or without any reasons that would make a person cough or wheeze, e.g. smoky environment.

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?

Inability to fall asleep, interrupted sleep or waking up earlier than usual.

B1.16. How much of a problem did you have with feeling sad, low or depressed?

Feeling tearful, having lost interest in things, feeling low and tired, not looking forward to anything.

B1.17.How much of a problem did you have with worry or anxiety?

Preoccupied more than usual with things that one would normally not worry about.

QUESTION SET 2

PART 3: QUESTIONS ON ACTIVITIES AND PARTICIPATION D1.1 - D6.8

Domain 1 includes questions about communication and thinking activities. Specific areas that are assessed include concentrating, remembering, problem solving, learning and communicating.

D1.1. How much difficulty did you have in concentrating on doing something for ten minutes?

This question is intended to determine the respondent's rating of difficulty with concentration for a short period, defined as 10 minutes. Generally, respondents have no problem understanding this item. If clarification is requested, however, respondents should be encouraged to think about their concentration in usual circumstances, not when they are preoccupied by a problem or in an unusually distracting environment. They may be cued to think about concentration while doing work tasks, reading, writing, drawing, playing a musical instrument, assembling a piece of equipment etc.

D1.2. How much difficulty did you have in remembering to do important things?

This is a question about memory for matters of day to day importance. It does not refer to memory for irrelevant content or to memory for detailed information from the past. Respondents should consider how well they remember to do things that are important to them or to their family. If note taking, electronic reminder systems or verbal cuing from personal assistants is usually in place as a memory aid, performance should be rated with this help taken into consideration.

D1.3. How much difficulty did you have in analysing and finding solutions to problems in day to day life?

This item refers to a complex activity involving many mental functions. If respondents are unsure, ask them to think about a problem they encountered in the past 30 days. Once a problem is identified, respondents should be asked to consider how well they:

• identified that a problem existed
• broke it down into manageable parts
• developed a list of possible solutions
• determined pros and cons of each solution
• determined the best solution given all considerations
• executed and evaluated the chosen solution
• selected an alternate solution if the first choice was not successful

D1.4. How much difficulty did you have in learning a new task, for example, learning how to get to a new place?

Learning a new route is offered as an example in this question however, respondents should not limit themselves to only this situation. If further clarification is requested or if the interviewer feels the respondent has difficulty to answer, the interviewer may ask the respondent to think about a situation in the past month where learning something new was required, such as learning a task at work (such as a new procedure or assignment), or a new activity (cooking, learning a language, a new sport).

When making the rating, respondents should consider how easily new information was acquired, how much assistance or repetition they needed in order to learn and how well what was learned was retained.

D1.5. How much difficulty did you have in generally understanding what people say?

The respondent should consider his/her usual mode of communication (i.e. spoken language, sign language, with an assistive device such as a hearing aid) and overall, rate the degree of difficulty in understanding the messages of others.

All situations encountered in the past 30 days by the individual should be considered, such as:

• when others speak quickly
• with background noise
• with distractions

Difficulties due to the fact that the language spoken is not one's mother tongue should be excluded when rating this question.

D1.6. How much difficulty did you have in starting and maintaining a conversation?

Both starting and maintaining conversation should be rated. If a respondent states that they have more trouble with starting than maintaining a conversation (or vice versa), they should average the amount of difficulty experienced with both activities to determine the final difficulty rating. Conversation includes use of whatever is the usual mode of communication (spoken, written, sign language, gestural). If assistive devices are used by the respondent for communication, the difficulty rating provided should take into account conversation while using those devices, assuming they are usually present. The respondent should consider any and all other factors of relevance to them in starting and maintaining a conversation such as hearing loss, language problems as after a stroke, stuttering, anxiety or any other factor related to a health condition.

Activities discussed in Domain 2 include standing, moving around inside the home, getting out of the home and walking a long distance.

D2.1. How much difficulty did you have in standing for long periods such as 30 minutes?

This question refers to situations where the person has to remain in a standing position for long time without leaning on something. For example, standing in a queue or waiting for a train.

D2.2. How much difficulty did you have in standing up from sitting down?

This question refers to standing up from sitting in a chair, on a bench or toilet. It does not refer to standing up from sitting on the floor.

D2.3. How much difficulty did you have in moving around inside your home?

This item refers to moving from room to room, and within rooms, using assistive devices or personal help that is usually in place. If the respondent lives in a house with multiple floors, this question also includes getting from one floor to another as needed. This will give a good idea of a person's mobility. A person who has problems moving inside the house is likely to have problems outside as well.

D2.4. How much difficulty did you have in getting out of your home?

This question seeks information about:

• mobility aspects of getting out of the home
• emotional or mental aspects of leaving the home (depression, anxiety, etc.)

For this question, "home" means the respondent's current dwelling, which might be a house, apartment, or nursing home.

D2.5. How much difficulty did you have in walking a long distance such as a kilometre [or equivalent]?

Distances should be converted into imperial measure where necessary.

Domain 3 asks about bathing, dressing, eating and staying alone.

D3.1. How much difficulty did you have in washing your whole body?

This question refers to washing one's entire body in the usual manner for the culture.

If respondents report that they have not washed their bodies in the past 30 days, interviewers should ask whether this is due to a health condition. If respondents report that it is due to a health condition, then the item should be coded "5" for extreme/cannot do. On the other hand, if respondents report that it is not due to a health condition, then the item should be coded "NA" for not applicable.

D3.2. How much difficulty did you have in getting dressed?

This question is intended to include all aspects of dressing the upper and lower body. Activities such as gathering clothing from storage areas (i.e. closet, dressers) and securing buttons, tying knots, etc., also should be considered when making the rating.

D3.3. How much difficulty did you have in eating?

This item refers to both feeding oneself (i.e. cutting food, getting food or drink from plate or glass to mouth) and swallowing (both food and drink). It also includes mental/emotional factors contributing to difficulty eating such as anorexia, bulimia, or depression. This question does not refer to meal preparation. If the respondent uses non-oral feeding (e.g.. tube feedings), this question refers to any difficulties experienced in self administering the non-oral feeding (e.g. feeding pump set up and cleaning).

D3.4. How much difficulty did you have in staying by yourself for a few days?

The intent of this question is to determine any difficulty staying alone for an extended period and remaining safe. If the individual did not experience this situation in the past 30 days, "not applicable" is the correct rating.

It is important for interviewers to probe responses of "none" for this question. This will help differentiate situations that were experienced without difficulty (in which case "1" is correct) from situations not experienced at all (in which case "NA" is correct).

Domain 4 assesses "getting along with people" and difficulties that might be encountered with these activities due to a health condition. In this context, "other people" may be those with whom one is intimate or one knows well (e.g. one's spouse or partner, one's family members or close friends), or those whom one does not know at all (e.g. strangers).

D4.1. How much difficulty did you have in dealing with people you do not know?

This item refers to interactions with strangers in any situation, such as:

• shop keepers
• service personnel
• asking someone for directions

When making the rating, respondents should consider both approaching such individuals, and interacting successfully with them to obtain their desired outcome.

D4.2. How much difficulty did you have in maintaining a friendship?

This includes:

• staying in touch
• interacting with friends in customary ways
• initiating activities with friends
• participating in activities when invited

If respondents report that they have not engaged in friendship-maintenance activities in the past 30 days interviewers should ask whether this is due to a health condition. If respondents report that it is due to a health condition, then the item should be coded "5" for extreme/cannot do. On the other hand, if respondents report that it is not due to a health condition, then the item should be coded "NA" for not applicable.

D4.3. How much difficulty did you have in getting along with people who are close to you?

The respondent should consider those relationships that he or she defines as close. These may or may not be family relationships.

D4.4. How much difficulty did you have in making new friends?

This includes:

• seeking opportunities to meet new people
• following up on invitations to get together
• social and communication actions to make contact and to develop a friendship

On occasion, participants will report that they have not engaged in friendship-making activities in the past 30 days. In this case, interviewers should ask whether this is due to a health condition (as defined by the WHODAS II). If respondents report that it is due to a health condition, then the item should be coded "5" for extreme/cannot do. On the other hand, if respondents report that it is not due to a health condition, then the item should be coded "NA" for not applicable.

D4.5. How much difficulty did you have in sexual activities?

The respondent should consider what he/she considers to be sexual activity when answering this question. However, if clarification is requested, this question refers to:

• sexual intercourse
• hugging
• kissing
• fondling
• other intimate or sexual acts

If respondent says "none", the interviewer should probe this response to determine whether there was no difficulty when engaging in sexual activities ("none" should be coded) or no difficulty because the respondent never engaged in such activities ("NA" should be coded).

This domain includes questions about difficulty in day to day activities. These activities are those that people do on most days and include household, work and school activities.

D5.1. How much difficulty did you have in taking care of your household responsibilities?

This is a global question intended to elicit the respondent's appraisal of difficulty encountered in maintaining the household and in caring for family members or others with whom one is close.

Activities include:

• physical,
• emotional,
• financial,
• psychological needs of the household or family.

In some cultures, males may indicate that they do not have household responsibilities. In this situation, it should be clarified that

Household responsibilities include:

• managing finances
• car and home repairs
• caring for the outside area of the home
• picking up children from school
• helping with homework
• disciplining children and
• other examples that interviewers believe elucidate the household responsibilities of males in the culture.

The term "household" is very broad. In the case of respondents who do not have a stable dwelling place, there are still activities surrounding the upkeep and maintenance of their belongings. This question refers to those activities.

D5.2. How much difficulty did you have in doing your most important household tasks well?

The respondent provides ratings based on his/her own appraisal of the quality in which household tasks and responsibilities are carried out.

D5.3. How much difficulty did you have in getting all the household work done that you needed to do?

The respondent provides ratings based on his/her own appraisal whether all needed household work gets done (quantity of work). If necessary, interviewers may remind respondents that they are to report difficulties due to the health condition, not those that may be experienced for other reasons such as not having enough time (unless this reason is somehow linked back to a health condition).

D5.4. How much difficulty did you have in getting your household work done as quickly as needed?

This question refers to the timely meeting of expectations and needs of those with whom one lives (or is close) with respect to household tasks and responsibilities.

D5.5. How much difficulty did you have in your day to day work/school?

This is a global question intended to elicit the respondent's appraisal of difficulties encountered in day to day work or school activities. This might include but is not limited to attending on time, responding to supervision, supervising others, planning and organizing and meeting expectations in the workplace.

D5.6. How much difficulty did you have in doing your most important work/school tasks well?

Doing work or school tasks "well" refers to completing them as expected by one's supervisor or teacher, by one's own standards or as specified in job or school performance criteria.

D5.7. How much difficulty did you have in getting all the work done that you need to do?

This question refers to meeting work expectations in terms of amount of work (quantity).

D5.8. How much difficulty did you have in getting your work done as quickly as needed?

This question refers to meeting time deadlines related to the work tasks.

Respondents are asked to consider how other people and the world in which they live restrict them in social participation, such as laws or other features. They must understand that they are not to report their own difficulties and activity limitations but rather problems encountered because of the society in which they live. In addition, questions are asked regarding the impact of the health condition. Respondents should be reminded that the focus is on the past 30 days.

D6.1. How much of a problem did you have in joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?

Examples of community activities include attending town meetings, fairs, leisure or sporting activities in the town, neighbourhood or community. The relevant issue being asked in this question is whether the individual is facilitated to participate in these activities or whether there are inhibitors to doing so.

If respondents are confused by the phrase "in the same way as anyone else can", they should be asked to use their best judgment to assess the extent to which average people in their community are able to join community activities, and then to compare their degree of difficulty in joining community activities in relation to this assessment.

If a person does not usually join in community activities "NA" will be recorded next to the question.

This question will allow to see if there is an element of exclusion because of the nature of a health condition.

D6.2. How much of a problem did you have because of barriers or hindrances in the world around you?

The intent of this question is to determine how much has stood in the way of the respondent being able to realize aspirations and plans as other people can. The concept here is external interference faced by the individual as created by the world or other people. Barriers could be physical such as the lack of ramps to get into church, social such as laws that discriminate against persons with disabilities and/or the negative attitudes of people that create the barrier.

D6.3. How much of a problem did you have living with dignity because of the attitudes and actions of others?

The respondent should consider problems he has had in living with stature or pride in who he is, what he is doing, and/or how he lives his life.

D6.4. How much time did you spend on your health condition, or its consequences?

This question intends to capture an overall rating or snapshot of the portion of the past 30 days spent by the respondent in dealing with any aspect of the health condition. This may include time spent for visits to a treatment centre, time spent managing financial matters related to the health condition, such as payment of bills, reimbursement of insurance or benefits, time spent in obtaining information about the health condition or in educating others about it, etc.

D6.5. How much have you been emotionally affected by your health condition?

This question refers to the degree to which the respondent has felt an emotional impact due to the health condition. Emotions may include anger, sorrow, regret, thankfulness, appreciation, or any other positive or negative emotions.

D6.6. How much has your health been a drain on the financial resources of you or your family?

Family is broadly defined to include relatives as well as those to whom the respondent is not related but considers to be like family, including those who may be sharing in the financial aspects of the health condition. The focus of this question is on the depletion of personal savings or current income to meet the needs created by a health condition. If a respondent has experienced a significant financial drain but the family has not, or vice versa, she should respond to the question based on the drain experienced by either party.

D6.7. How much of a problem did your family have because of your health problems?

The focus here is on problems created by the interaction of this health condition with the world in which the person lives. The question seeks information on problems that are borne by the family, which might include financial, emotional, physical problems, etc. Note the definition of family as stated in D6.6.

D6.8. How much of a problem did you have in doing things by yourself for relaxation or pleasure?

The respondent should consider leisure interests which are currently pursued and those that he/she would like to pursue but cannot due to the health condition and restrictions imposed by the society. Examples might include a respondent who has the desire to read novels but is restricted from doing so because the local library does not carry large print books for use by individuals with low vision or a respondent who enjoys watching movies on video but cannot do so because very few are produced with subtitles for the deaf. An overall rating of problems encountered should be provided.

QUESTION SET 2

PART 4: QUESTIONS ON NEED FOR ASSISTANCE E1 - E4

These questions ask whether the respondent is in need of a personal assistance in order to carry out certain activities, such as self care, movement and communication.

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.

Examples of personal assistance for self care may include family members or professional caretakers who assist the person in washing or dressing.

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.

This question refers to personal assistance for movement activities such as a family member who helps the person moving inside or outside the home or a passenger who helps the person getting in and out of the bus.

E3. Do you ever need someone to help with, or be with you for, communication activities?

For example: understanding, or being understood by, others.

Personal help for communication activities include family members, friends or professional helper (e.g. sign language interpreter) who assist the person in communicating.

E4. What are the reasons for the need for assistance or supervision shown in questions E1, E2, and E3?

This question invites the respondent to provide the underlying reasons for the need for assistance. The response categories of 'Long-term health condition', 'disability' and 'old age (old or young age response combined with respondent age data)' are considered as indicative for having a need for core activity assistance. If only other reasons are given (e.g. d ifficulty with English language), the respondent is not viewed as having a need for core activity assistance.