Validation of the World Health

Organizations Quality of Life

Questionnaire with Parents of Children
with Autistic Disorder

Latefa A.Dardas & Muayyad M.Ahmad

Journal of Autism and

Developmental Disorders

ISSN 0162-3257
Volume 44
Number 9

J Autism Dev Disord (2014)

44:2257-2263
DOI 10.1007/s10803-014-2110-1

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 Author's personal copy
J Autism Dev Disord (2014) 44:22572263
DOI 10.1007/s10803-014-2110-1
ORIGINAL PAPER
Validation of the World Health Organizations Quality of Life
Questionnaire with Parents of Children with Autistic Disorder
Latefa A. Dardas Muayyad M. Ahmad
Published online: 3 April 2014
Springer Science+Business Media New York 2014
Abstract The World Health Organizations Quality of
Life Questionnaire-BREF (WHOQOL-BREF) has been
used in many studies that target parents of children with
Autistic Disorder. However, the measure has yet to be
validated and adapted to this sample group whose daily
experiences are considered substantially different from
those of parents of children with typical development and
parents of children with other disabilities. Therefore, this
study was designed to examine the psychometric properties
and the theoretical structure of the WHOQOL-BREF with
a sample of 184 parents of children with Autistic Disorder.
The factor structure for the WHOQOL-BREF was exam-
ined using exploratory and confirmatory factor analyses.
Our analyses provided no evidence of a better model than
the original 4-domain model. Nevertheless, some items in
the measure were re-distributed to different domains based
on theoretical meanings and/or clean loading criteria. The
new model structure gained the measures required validity
with parents of children with Autistic Disorder.
Keywords WHOQOL-BREF
Factor analysis

Autistic Disorder
Quality of life
Psychometrics
Introduction
It is imperative that interest in the Quality of Life (QoL)
arena has expanded and researchers have recognized the
L. A. Dardas (&)
M. M. Ahmad
Faculty of Nursing, The University of Jordan, Amman 11942,
Jordan
e-mail: l.dardas@ju.edu.jo; latefadora@yahoo.com
M. M. Ahmad
e-mail: mma4@ju.edu.jo; mma4jo@yahoo.com
importance of studying individuals QoL as means to
shape, direct, and evaluate health programs. One of the
most recognized definitions of the construct of QoL is the
one adopted from the World Health Organization; Quality
of life is defined as individuals perceptions of their posi-
tion in life in the context of culture and value systems in
which they live and in relation to their goals, expectations,
standards and concerns. (WHO 1996, p. 5). The construct
of QoL is heavily influenced by personal and environ-
mental factors and their interactions. Therefore, con-
structing a valid measurement for QoL requires paying
attention to the uniqueness of individuals experiences.
The World Health Organizations Quality of Life
Questionnaire- BREF (WHOQOL-BREF) is considered
one of the most commonly used measures of QoL. It is the
result of years of development research on QoL and health
care (WHOQOL Group 1998). The WHOQOL-BREF has
its conceptual, methodological, and psychometric strengths
and is considered a sound and cross-culturally valid
assessment of QoL. Nevertheless, research must assess the
measure with structured diagnostic samples to confirm its
appropriateness to those specific samples (Skevington et al.
2004).
Parenting a child with a chronic pervasive disability is
considered one of the most stressful situations for parents
(Dardas and Ahmad 2014a, b; Ericzon et al. 2005). Con-
sidering that Autistic Disorder is one of the most common
childhood chronic developmental disorders, establishing a
reliable and valid measure of QoL for involved parents is
crucial for both research and clinical assessment purposes.
The WHOQOL-BREF was used in many studies that tar-
geted parents of children with Autistic Disorder (e.g.,
Mungo et al. 2007). However, the measure has never been
adapted for this sample. Previous studies have uniformly
found that the lived experiences of parents of children with
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2258
Autistic Disorder are substantially different from those of
parents of children with typical development and parents of
children with other disabilities (Ericzon et al. 2005; Seltzer
et al. 2004). As such, assuming that the WHOQOL-BREF
is valid across samples including those with pervasive
disabilities may guide us to inappropriate conclusions.
Therefore, the purpose of this study was to validate the
WHOQOL-BREF with parents of children with Autistic
Disorder using exploratory factor analysis (EFA) and
confirmatory factor analysis (CFA).
Methods
This study was granted ethical approval from the Deanship
of the Academic Research at the University of Jordan.
Participants were advised of the purpose and methods of
the study before attaining their voluntary involvement in
tool completion. Participants were assured that their par-
ticipation was completely voluntary and that they had the
right to withdraw at any time without adverse impact on
their childrens care. An identification number was
assigned to each participant to assure the confidentiality of
the data obtained. Electronic data were kept on a password-
protected computer.
Participants
According to Nunnally and Bernsteins (1994) guideline,
five to ten cases per item are required to estimate the
sample size needed for running factor analyses. The ori-
ginal WHOQOL-BREF includes a total number of 24
items. Thus, the sample size should range from 120 to 240.
A total of 184 participants were included in this study.
Among them, 38 % (n = 70) were fathers. The mean age
for the parents was 37 years (SD = 7.6). The vast majority
(96.7 %; n = 178) were married. About 46 % (n = 85) of
the parents had secondary school or less, 24 % (n = 44)
had diplomas, and 30 % (n = 55) had baccalaureate
degrees or higher. The mean family monthly income was
about 500 Jordanian Dinars (JD) (1 JD = 1.4 US Dollar).
Using the DSM-IV criteria (APA 2000), all children had
been diagnosed with Autistic Disorder by certified pro-
fessionals. The majority of children (84 %) were boys. The
range of the childrens age was between 2 and 12 years
(mean = 6.3, SD = 3).
Measure
The WHOQOL-BREF is an abbreviated 26-item version of
the WHOQOL-100. The WHOQOL-BREF contains one
item selected from each of the 24 QoL facets that are
included in the WHOQOL-100, in addition to two
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individual items derived from the general facet on overall
QoL and health. The measure includes four domains;
Physical health, Psychological health, Social relations, and
Environment. The score of items responses in all domains
ranges between 1 (very dissatisfied/very poor) and 5 (very
satisfied/very good) (WHOQOL Group 1998).
The WHOQOL-BREF was developed through a col-
laboration of several centers around the world. The mea-
sure consists of QoL items that are concerned with how
satisfactory the respondents experience of different
aspects of life has been (WHOQOL Group 1998). The
WHOQOL-BREF was translated and validated by the
WHOQOL Group in several languages. The translation
process was run simultaneously around the world using
common protocols that were agreed upon through inter-
national consensus at each stage of the development pro-
cess (Skevington 2002; WHO 1996). This process
permitted a high level of semantic and conceptual equiv-
alence to be achieved between language versions (WHO-
QOL Group 1998). The validated Arabic translation of the
WHOQOL-BREF was used in this study after gaining
permission from the WHO permission and licensing center.
The Arabic translation of the WHOQOL-BREF showed
highly significant validity and reliability indices (Dardas
2014; Dardas and Ahmad 2013a; Ohaeri et al. 2007, 2009).
The properties of the WHOQOL-BREF have been
assessed by the WHOQOL Group through a large survey of
11,830 adults from 23 countries (Skevington et al. 2004).
The study assessed the WHOQOL-BREF reliability and
validity through confirmatory factor analysis and indicated
that the WHOQOL-BREF has good to excellent psycho-
metric properties and may have a place among the leading
generic QoL measures.
Results
A principal components analysis with Varimax rotation
was performed with the 24 items in the WHOQOL-BREF.
Based on how strongly and cleanly the variables load on
the factors, the number of factors to be extracted can be
determined (Munro 2005). A variable loads strongly if its
loading is C.40 in a particular factor, and is considered
clean if the absolute difference between loadings exceeds
.20 (Nunnally and Bernstein 1994). Accordingly, the
modified model ended with the same number of items in
the original model. However, five items were moved to
other domains based on theoretical meaning and/or clean
loading criteria. Items 15 and 18 were moved from phys-
ical health to social relationship, items 11, 19 were moved
from psychological health to social relationship; and item 8
was moved from environment to psychological health.
Table 1 presents the 24 items loading on the new model
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Table 1 Exploratory factor Item # Principal components with varimax rotation

analysis of the WHOQOL-
BREF with the total sample Social Psychological Environment Physical
(n = 184) relationship health health

Q19 How satisfied are you with yourself? .72 .25 .19 .21
Q20 How satisfied are you with your personal .71 .20 .23
relationships?
Q18 How satisfied are you with your capacity .69 .19 .33
for work?
Q11 Are you able to accept your bodily .69 .19 .23
appearance?
Q21 How satisfied are you with your sex life? .64 .38 .16 -.13
Q22 How satisfied are you with the support you .58 .26 .38
get from your friends?
Q15 How well are you able to get around? .49 .33 .19 .24
Q7 How well are you able to concentrate? .26 .76 .22
Q6 To what extent do you feel your life to be .27 .74 .10
meaningful?
Q5 How much do you enjoy life? .37 .66 .27
Q8 How safe do you feel in your daily life? .35 .65 .21 .22
Q26 How often do you have negative feelings .30 .47 .32 .30
such as blue mood, despair, anxiety,
depression?
Q25 How satisfied are you with your transport? .16 .75
Q24 How satisfied are you with your access to .18 -.14 .69
health services?
Q23 How satisfied are you with the conditions .27 .41 .63
of your living place?
Q12 Have you enough money to meet your .43 .52 .28
needs?
Q9 How healthy is your physical environment? .32 .51 .23
Q14 To what extent do you have the opportunity .30 .48 .36
for pleasure activities?
Q13 How available to you is the information .23 .27 .42 .29
that you need in your day-to-day life?
Q3 To what extent do you feel that physical pain .14 .12 .82
prevents you from doing what you need to do?
Q4 How much do you need any medical .10 .76
treatment to function in your daily life?
Q17 How satisfied are you with your ability to .49 .16 .12 .63
perform your daily living activities?
Bolded numbers mean that Q10 Do you have enough energy for everyday .33 .42 .59
items have adequate loading life?

Item loading of \.10 Q16 How satisfied are you with your sleep? .36 .20 .28 .40

percentage of the variance % Variance 38.08 7.80 6.61 5.35

accounted for each factor

and the cumulative variance accounted for with the entire
sample which was 57.85 %.
Factor Analysis
We used both of EFA and CFA to examine the structure
stability of the WHOQOL-BREF among parents of chil-
dren with Autistic Disorder. The aim of EFA is to
summarize data by aligning together inter-correlated vari-
ables. On the other hand, CFA requires the estimation and
specification of the hypothesized model by setting latent
variables (factors) to account for covariance among a set of
observed variables (Ahmad 2010, 2005; Brown 2006;
Dardas and Ahmad 2013b). Bartletts Test of Sphericity
evaluates all factors in the model together and each factor
separately against a hypothesis stating that there are no

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Table 2 Cronbachs alpha and items distribution in original and new model
Domain Original model
Items
Physical health 3, 4, 10, 15, 16, 17, 18
Psychological health 5, 6, 7, 11, 19, 26
Social relationship 20, 21, 22
Environment 8, 9, 12, 13, 14, 23, 24, 25
factors (Tabachnick and Fidell 2001). In this study, the
Bartletts Test indicated that satisfactory shared variance
was present (p \ .001). The zero-order correlations were
compared to the partial correlations between pairs of
variables by using Kaiser-Meyer-Oklin measure (KMO)
(Munro 2005). The KMO in EFA in the new model was
.90. According to Kaiser (1974), if KMO is more than .50,
it is considered acceptable. Norusis (1998) stated that
correlations between variables are considered better if the
KMO is close to 1. The new model for the WHOQOL-
BREF measure in this study was identified by four inter-
related constructs. Compared to the original model, the
Cronbachs alphas in this model were higher in two
domains, same in one, and lower in the fourth domain,
resulting in .93 for the total score (Table 2).
Confirmatory factor analysis was performed through the
Analysis of Moment Structure (AMOS, version 21.0) sta-
tistical package using the estimation method of the Maxi-
mum Likelihood over the variancecovariance matrix for
the four-factor model (Arbuckle 2012). In order to achieve
model identification, regression coefficients of the error
terms over the endogenous variables were fixed to 1. The
CFA was performed to determine if the hypothesized sta-
tistical model fits the actual data set by using a number of
goodness-of-fit statistics. Normality assessment is usually
rejected if the skewness ratio is more than 1, and/or
kurtosis is more than 2 (Nunnally and Bernstein 1994).
The 24 items distribution in this study was accepted as
none of them breached normality.
Following AMOS analysis guideline (Arbuckle 2012),
Factors (latent variables) were presented in circles; Items
(observed indicators) were presented in rectangles; and
Measurement Errors appeared in ellipses. The structural
model was identified by four constructs (Physical health,
Psychological health, Social relationship, and Environ-
ment) inter-correlated to each other with double-headed
arrows (Fig. 1). The single-headed arrows from circles to
the rectangles represented regression paths that show the
links between the factors and their corresponding set of
items. Factor loadings were represented by the coefficients
on the paths. Further, the single-headed arrows from
ellipses to rectangles showed the measurement error asso-
ciated with each item.
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Model after EFA
Reliability Items Reliability
.83 3, 4, 17, 10, 16 .81
.84 7, 6, 5, 8, 26 .85
.67 19, 20, 18, 11, 21, 15, 22 .84
.82 25, 24, 23, 12, 9, 14, 13 .82
March et al. (1996) recommended considering multiple
fit indices to examine the strength of the scale structure.
The typically used fit statistics include the goodness of fit
index (GFI), comparative fit index (CFI), and incremental
fit index (IFI). All these indices have a range from 0 to 1,
with values above .90 indicating a good fit (Wang et al.
1996). The root mean square error of approximation
(RMSEA) that exceeds .1 warrants rejecting the model,
while values equal .05 or less indicate a close fit (Browne
and Cudeck 1989). Table 3 shows the goodness-of-fit
indices of the modified model.
Discussion
The purpose of this study was to validate the WHOQOL-
BREF with parents of children with Autistic Disorder using
EFA and CFA techniques. Overall, the results confirmed
that the 4- domain model of the WHOQOL-BREF (Phys-
ical, Psychological, Social and Environment) fits the data
well. Our analyses ended with the same number of items in
the original model. Nevertheless, five items were moved to
other domains based on theoretical meaning and/or clean
loading criteria. All the moved items did not load suffi-
ciently with their original factors. Further, the items were
more consistent with the notion of the domains to which
they were moved.
Item 8 which inquires about how safe the respondent
feels in daily life was more strongly associated with the
psychological domain than its original domain; environ-
ment. Thus, the conceptualization of this item appears to
depart from the theoretical concept. This finding is sup-
ported by the study of Skevington et al. (2004) which also
failed to support the original distribution for this item and
recommended either moving it to the psychological domain
or changing the wording and semantics of its translation to
reinforce the intended concept. Skevington, Lotfy, and
OConnell have also stated that because no evidence of
these associations was found during the development of the
WHOQOL-100 from which the WHOQOL-BREF was
derived, it is possible that the format of the WHOQOL-
BREF caused a change in the context of the measure and
consequently the conceptualization of the item by
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Fig. 1 Standardized estimates

for the modified WHOQOL-
BREF Model with parents of
children with Autistic Disorder

Table 3 Goodness-of-Fit Indices for the modified model respondents. This possibility warrants giving attention to
Parameters Score the resulted structure of the measure during the develop-
ment and translation processes.
Number of parameters 54 According to the WHOQOL Group (1998), item 15 was
Chi square 615.63* extracted from the physical health domain and was
Degree of freedom 246 assumed to inquire about the participants physical ability
Relative Chi square (v2/df) 2.50 to move freely. Our analysis showed that for parents of
Goodness of fit index .90 children with Autistic Disorder, this item identifies better in
Adjusted goodness of fit index .87 the social domain. In other words, parents perceptions
Comparative fit index .91 regarding their ability to move around were related to
Increment fit index .91 social factors rather than the intended physical ones. This
Root mean square error of approximation. .08 result can be explained by referring to the special care-
* p \ .001 giving experiences that those parents have. Children with

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Autistic Disorder are often sensitive to change in daily
routines and surrounding environments (Rogers and Ozo-
noff 2005). Thus, simple tasks that may be performed
smoothly with typical children (e.g., walking in the street)
can cause significant distress for children with Autistic
Disorder who may react in compulsive and stereotypical
manner that appears peculiar to others and embarrassing to
the parents (McClintock et al. 2003). Consequently,
involvement in activities that include social contact is
considered one of the most difficult challenges for parents
of children with Autistic Disorder who in turn may choose
to withdraw from social activities and experience restric-
tions to family activities (Gray 2002).
With regard to item 18 which inquires about the partici-
pants satisfaction with their capacity for work, our analysis
resulted in moving this item from the physical domain to the
social domain. The parenting experience for children with
Autistic Disorder can also help in partially explaining this
finding. It has been documented in the literature that parents
inability to maintain job stability is considered among the
most significant effects of raising a child with Autistic
Disorder (Swensen et al. 2003). The chronicity of the childs
disturbing and disruptive behaviors mandate consistent
caregiving. As a result, many parents (especially mothers)
report that they have to give up job and stay at home (Parish
et al. 2004). A review of the literature on the social support
needs of mothers of children with Autistic Disorder have
found that spending time in contact with supportive family
members and parents of other children with Autistic Dis-
order can significantly decrease parental stress (Boyd 2002).
This was supported by Higgins et al. (2005) who found
spousal support an effective coping strategy for parents
providing care to children with Autistic Disorder. As such,
mothers for example may choose to withdraw from paid
employments and try to maintain ordinary relationships with
other family members and support groups. Given the prior
discussion, our results regarding the department of item 18
from the physical to social domain may not be surprising.
However, we suggest that for this item to measure specifi-
cally parents of children with Autistic Disorder physical
ability to work, attention should be given to changing the
wording of its translation to reinforce the concept of work
physical capacity.
Items 11 and 19 (Are you able to accept your bodily
appearance?; how satisfied are you with yourself?) were
moved from psychological health to social relationship
domain. Although the items are assumed to measure psy-
chological health, we found that they identify better with the
social health domain. Indeed, the psychological and social
aspects of ones health have many mutually interdependent
influences. Psychological aspects like body image, self-
satisfaction, and self-esteem are all critical factors in shap-
ing individuals ability to initiate and maintain social
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J Autism Dev Disord (2014) 44:22572263
relationships. According to Maslow (1987), for the psy-
chological health to be achieved, the essential core of the
person should be fundamentally accepted and respected by
others and by self. Maslow has also stated that without the
fulfillment of the self-esteem needs (which includes inputs
from others), individuals will be unable to grow and obtain
self-actualization. This is also supported by Sociometers
theory (1995) which maintains that how people are satisfied
with themselves is influenced by their level of status and
acceptance in their social group. It can be therefore con-
cluded that, individuals who have a positive body image, are
satisfied with themselves and their achievements, and who
feel they worth and others value them are expected to be
more successful in their social life and more in control of
their relationships. On the other hand, how others perceive
an individual can heavily influence the latters sense of
worthiness, pride and discouragement.
Conclusion
It has been recently highlighted that consistency in using
measures in family research is needed (IASSID 2012). The
findings revealed in this study set out to assess the appli-
cability of the WHOQOL-BREF to the group of parents of
children with Autistic Disorder. Exploratory factor analy-
ses with varimax rotation provided no evidence of a better
model than the original 4-domain model. Confirmatory
factor analyses were run to re-evaluate the fit values found
for the original 4-domain model. The results were accept-
able, yet five items have been re-distributed to different
domains. The analyses indicate that the new distribution of
the WHOQOL-BREF structure gained the required validity
of the measure with the sample of parents of children with
Autistic Disorder. The four-factor model was found to be
valid, reliable, parsimonious, and empirically supported.
However, before a final recommendation is made to have
all parents of children with Autistic Disorder use the
modified structure of the WHOQOL-BREF, more research
needs to be done with a larger and more varied sample.
Further, additional work is needed to examine the mea-
sures testretest reliability and its concurrent validity in
comparison to other relevant measures.
Acknowledgments The authors gratefully acknowledge the partial
funding for this study provided by The University of Jordan. The
authors are indebted to Dr. Rafat Qahoush for his valuable contribution.
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