NCHS Questionnaire Design Research Laboratory - testing Washington Group International Disability Questions

Attachment 2- Testing Instrument/ Washington Group International Disability Questions

[Note to reviewers: Participants will be asked both sets of questions, but the order will be randomized.]

OMB #0920-0222; Expiration Date: 02/28/10

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Introductory phrase:

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

1. The Expanded Short Set

1) No – no difficulty; 2) Yes – some difficulty; 3) Yes – a lot of difficulty; 4) Cannot do at all

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

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

3. Do you have difficulty walking or climbing steps?

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

5. Using your usual (customary) language, do you have difficulty communicating, for example understanding or being understood?

6. Do you have difficulty remembering or concentrating?

7. Do you have difficulty raising a 2 litre jug of water from waist to eye level?

8. a) For Children: [Do you / Does (name)] have difficulty learning new things?

b) For Adults: Do you have difficulty understanding and using information like

following directions to get to a new place?

(Pain, affect and fatigue – not able to measure using a single question therefore not included)

Introductory phrase:

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

2. The Extended set

1. Vision

Q1.1 Do you wear glasses or contact lenses?

1)Yes; 2) No

Interviewer: If “yes” to Q1.1, mention aid in Q1.2 and Q1.3.

Q1.2 Do you have difficulty clearly seeing someone’s face across a room [even if wearing your glasses or contact lenses]?

1) No – no difficulty; 2) Yes – some difficulty; 3) Yes – a lot of difficulty; 4) Cannot do at all

Q1.3 Do you have difficulty clearly seeing the picture on a coin [even if wearing your glasses or contacts]?

1) No – no difficulty; 2) Yes – some difficulty; 3) Yes – a lot of difficulty; 4) Cannot do at all

2. Hearing

Q2.1 Do you use a hearing aid?

1) Yes 2) No

Interviewer: If “yes” to Q2.1, read aid phrase in Q2.2 and Q2.3.

Q2.2 Do you have difficulty hearing what is said in a conversation with one other person in a noisy room [even if using your hearing aid]?

1) No – no difficulty; 2) Yes – some difficulty; 3) Yes – a lot of difficulty; 4) Cannot do at all

Interviewer: If “no difficulty” to Q2.2, skip Q2.3

Q2.3 Do you have difficulty hearing what is said in a conversation with one other person in a quiet room [when wearing your hearing aid]?

1) No – no difficulty; 2) Yes – some difficulty; 3) Yes – a lot of difficulty; 4) Cannot do at all

3. Mobility

Q3.1 Do you use any aids or equipment or receive help for walking or climbing steps?

1) Yes 2) No

Interviewer: If “no” to Q3.1, skip to Q3.3.

Q3.2 Which of the following types of aids or equipment do you use?

Interviewer: Read the following list and record responses to each:

a. cane or walking stick? 1. yes 2. no

b. walker? 1. yes 2. no

c. crutches? 1. yes 2. no

d. wheelchair? 1. yes 2. no

e. someone’s assistance? 1. yes 2. no

f. other? (specify: ________) 1. yes 2. no

Interviewer: If “yes” to Q3.1, read aid phrase in Q3.3, Q3.4 and Q3.5.

Q3.3 Do you have difficulty walking 500 meters on level ground, that would be about _________ (insert country-specific example) [without using your (insert aid(s) recorded in Q3.2)]?

1) No – no difficulty; 2) Yes – some difficulty; 3) Yes – a lot of difficulty; 4) Cannot do at all

Q3.4 Do you have difficulty walking 100 meters on level ground, that would be about _________ (insert country-specific example) [without using your (insert aid(s) recorded in Q3.2)]?

1) No – no difficulty; 2) Yes – some difficulty; 3) Yes – a lot of difficulty; 4) Cannot do at all

Q3.5 Do you have difficulty walking up and down [insert country-specific example: a flight of stairs / 12 steps / a small hill] [without using your (insert aid(s) recorded in Q3.2)]?

1) No – no difficulty; 2) Yes – some difficulty; 3) Yes – a lot of difficulty; 4) Cannot do at all

Interviewer: If “no” to Q3.1, skip Q3.6, Q3.7, and Q3.8.

Q3.6 Do you have difficulty walking 500 meters on level ground, that would be about _________ (insert country-specific example) [even if using your (insert aid(s) recorded in Q3.2)]?

1) No – no difficulty; 2) Yes – some difficulty; 3) Yes – a lot of difficulty; 4) Cannot do at all

Q3.7 Do you have difficulty walking 100 meters on level ground, that would be about _________ (insert country-specific example) [even if using your (insert aid(s) recorded in Q3.2)]?

1) No – no difficulty; 2) Yes – some difficulty; 3) Yes – a lot of difficulty; 4) Cannot do at all

Q3.8 Do you have difficulty walking up and down [insert country-specific example: a flight of stairs / 12 steps / a small hill] [even if using your (insert aid(s) recorded in Q3.2)]?

1) No – no difficulty; 2) Yes – some difficulty; 3) Yes – a lot of difficulty; 4) Cannot do at all

4. Communication

Q4.1 Do you have difficulty speaking clearly (that is, using spoken language)?

1) No – no difficulty; 2) Yes – some difficulty; 3) Yes – a lot of difficulty; 4) Cannot do at all

Q4.2 Do you have difficulty making yourself understood when speaking?

1) No – no difficulty; 2) Yes – some difficulty; 3) Yes – a lot of difficulty; 4) Cannot do at all

Interviewer: If “difficulty” to Q4.1 or Q4.2, ask Q4.3.

Q4.3 Are you able to communicate any easier when using one of these non-spoken forms of communication?

Interviewer: Read the following list and record all affirmative responses:

a. sign language? 1. yes 2. no

b. hand writing? 1. yes 2. no

c. typed or text messages? 1. yes 2. no

d. communication or picture board or cards? 1. yes 2. no

e. an interpreter? 1. yes 2. no

f. other? (specify: ________) 1. yes 2. no

5. Cognition

Two sets of questions were proposed for cognitive testing.

Set 5 A:

Q5A.1 On how many days during the last week have you had difficulty remembering important things?

Record number of days: ­­­­____________

Q5A.2 Thinking about the last time you had difficulty remembering, how much difficulty did you have?

• Would you say 1) no difficulty, 2) a little difficulty, 3) a lot of difficulty, or 4) were you unable to do this?

OR

• Would you say 1) no difficulty, 2) a little difficulty, 3) a lot of difficulty, 4) something in between a little and a lot of difficulty, or 5) were you unable to do this?

Set 5B:

Q5B.1 Do you have difficulty remembering a few things, a lot of things, or something in between?

1) a few things; 2) something in between; 3) a lot of things

6. Upper Body

Q6.1 Do you have difficulty raising a 2 litre jug of water from waist to eye level?

1) No – no difficulty; 2) Yes – some difficulty; 3) Yes – a lot of difficulty; 4) Cannot do at all

Q6.2 Do you have difficulty using your hands and fingers, such as picking up small objects or opening or closing containers?

1) No – no difficulty; 2) Yes – some difficulty; 3) Yes – a lot of difficulty; 4) Cannot do at all

Q6.3 Do you use any special equipment or receive help with lifting, carrying or using your hands your hands or finger?

1) Yes; 2) No

7. Affect

Set 8A:

Anxiety:

Q8A.1. How often during the past year did you feel anxious?

1. Not at all; 2) Daily; 3) Weekly; 4) Monthly

Interviewer: If “not at all” to Q8A.1, skip to Q8A.4.

Q8A.2 Do you take any medication for anxiety?

2. Yes; 2) No

Interviewer: If “yes” to Q8A.2, read medication phrase in Q8A.3.

Q8A.3 Thinking about the last time you felt anxious, how would you describe your level of anxiety [even when taking your medication]?

Would you say 1) none, 2) a little, 3) a lot, or 4) something in between a little and a lot?

Depression:

Q8A.4 How often during the past year did you feel depressed?

1) Not at all; 2) Daily; 3) Weekly; 4) Monthly

Interviewer: If “not at all” to Q8A.4, skip to next domain

8A.5 Do you take any medication for depression?

1) Yes; 2) No

Interviewer: If “yes” to Q8A.5, read medication phrase in Q8A.6.

Q8A.6 Thinking about the last time you felt depressed, how would you describe your level of depression [even when taking your medication]?

Would you say 1) none, 2) a little, 3) a lot, or 4) something in between a little and a lot?

Set 8B:

Q8B.1 Do you take any medication for anxiety or depression?

1) Yes; 2) No

Interviewer: If ‘no’ to Q8B.1, skip to next domain.

Q8B.2 On how many weeks during the past year did you feel anxious?

Record number of weeks: _________________

Interviewer: If “yes” to Q8B.1, read medication phrase in Q8B.3.

Q8B.3 During those times when you felt anxious, how would you describe your level of anxiety [even when taking your medication]?

Would you say 1) none, 2) a little, 3) a lot, or 4) something in between a little and a lot?

Q8B.4 On how many weeks during the past year did you feel depressed?

Record number of weeks: _________________

Interviewer: If “yes” to Q8B.1, read medication phrase in Q8B.5.

Q8B.5 During those times when you felt anxious, how would you describe your level of depression [even when taking your medication]?

Would you say 1) none, 2) a little, 3) a lot, or 4) something in between a little and a lot?

8. Pain

Set 9A:

Q9A.1 Do you use medication for pain? - or - Are you taking medication for pain?

1)Yes; 2) No

Q9A.2 On how many days during the past week did you have pain?

Would you say 1) none, 2) 1-2 days, 3) 3-4 days, or 4) 5 or more days?

Interviewer: If “none” to Q9A.2, skip Q9A.3 and Q9A.4.

Interviewer: If “yes” to Q9A.1, read medication phrase in Q9A.3, Q9A.4 and Q9A.5.

Q9A.3 Thinking about the last time you had pain, how long did the pain last [even when taking your medication]?

Would you say 1) under 1 hour, 2) 1-2 hours, or 3) more than 2 hours?

Q9A.4 Thinking about the last time you had pain, how would you describe the level of pain [even when taking your medication]?

Would you say it was 1) none, 2) a little, 3) a lot, or 4) somewhere in between a little and a lot?

Q9A.5 Thinking about the last time you had pain, was your experience of pain usual, worse than usual, or better than usual [even when taking your medication]?

1) The same as usual; 2) Worse than usual; 3) Better than usual

Set 9B:

Q9B.1 Do you have chronic or frequent pain?

1) Yes; 2) No

Q9B.2 Do you use medication for pain? - or – Are you taking medication for pain?

1)Yes; b) No

Interviewer: If “no” to Q9B.1, skip Q9B.3.

Interviewer: If “yes” to Q9B.2, read medication phrase in Q9B.3.

Q9B.3 Thinking about the last you had pain, how would you describe the level of pain [even when taking your medication]?

Would you say it was 1) none, 2) a little, 3) a lot, or 4) somewhere in between a little and a lot?

9. Fatigue

Q10.1 Do you have chronic or frequent feelings of being tired?

1) Yes; 2) No

Q10.2 How often during the past year did you have chronic or frequent feelings of being tired?

Would you say 1) daily, 2) weekly, 3) monthly, 3) less than monthly, or 4) not at all?

Interviewer: If “not at all” to Q10.2, skip Q10.3.

Q10.3 Thinking about the last time you felt tired, how would you describe the level of tiredness?

Would you say it was 1) none, 2) a little, 3) a lot, or 4) somewhere in between a little and a lot?

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