**Appendix 1: Question batteries and question by question
specifications**

**[Washington Group short question set]{.underline}**

# [Core Questions]{.underline}:

**Introduction**

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

A.  Objective

The purpose of the introduction is to get the respondent to focus on
difficulties they may have that are the result of some physical or
mental health problem. Since persons living in developing countries may
not have access to Western medicine which would provide a diagnosed
'condition', the term problem was substituted. However, condition can be
used interchangeably with the term problem if that facilitates the
respondent understanding the context. We are interested in establishing
difficulties that occur within a health context rather than those caused
by a lack of resources.

B.  Definitions

> [Health]{.underline} refers to the general condition of the body or
> mind with reference to soundness, vitality, and freedom from disease.
>
> [Problem]{.underline} refers to the respondent's perception of a
> departure from physical, mental or emotional well-being. This includes
> specific health problems such as a disease or chronic condition, a
> missing limb or organ or any type of impairment. It also includes more
> vague disorders not always thought of as health-related such as
> senility, depression, retardation, drug dependency, accidental
> injuries, etc.

**Questions**

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

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a.  **No - no difficulty**

b.  **Yes -- some difficulty**

c.  **Yes -- a lot of difficulty**

d.  **Cannot do at all**

Alternative wording for proxy respondent:

1)  **Does {person} have difficulty seeing, *even if wearing glasses*?**

    a.  **No - no difficulty**

    b.  **Yes -- some difficulty**

    c.  **Yes -- a lot of difficulty**

    d.  **Cannot do at all**

A. Objective

The purpose of this item is to identify persons who have vision
difficulties or problems of any kind even when wearing glasses (if they
wear glasses). They can have a problem seeing things close up or far
away. They may not be able to see out of one eye or they may be only
able to see directly in front of them, but not to the sides. Any
difficulty with vision that they consider a problem should be captured.

B. Definition/s

[Seeing]{.underline} refers to an individual using his/her eyes and
visual capacity in order to perceive or observe what is happening around
them.

C. Instructions

Two versions of the questions are provided; one for self-respondents and
one for proxy respondents. A proxy respondent (i.e. a close family
member) may be needed if the respondent is not able to answer for
themselves. Note if the person is wearing glasses and make sure that
they understand that the question refers to difficulties they may have
while they are wearing their glasses.

The answer categories are set up so that the respondent can indicate
'yes', 'no' or that they cannot do it easily. However people aren't
always sure how much difficulty is considered to be enough for a 'yes'
answer. So they usually qualify their 'yes' with comments about their
experience such as 'yes', I have a little problem or 'yes sometimes',
or, when the problem is very serious, they indicate 'Oh, yes, a lot'.
These answer categories try to capture that process. They may have to be
repeated for the first one or two questions in order for the respondent
to get familiar with the choices.

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

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a.  **No- no difficulty**

b.  **Yes -- some difficulty**

c.  **Yes -- a lot** **of difficulty**

d.  **Cannot do at all**

Alternative wording for proxy respondent:

2)  **Does {person} have difficulty hearing, *even if using a hearing
    aid*?**

    a.  **No- no difficulty**

    b.  **Yes -- some difficulty**

    c.  **Yes -- a lot** **of difficulty**

    d.  **Cannot do at all**

A. Objective

The purpose of this item is to identify persons who have some hearing
limitation or problems of any kind with their hearing even when using a
hearing aid (if they wear a hearing aid). They can have a problem
hearing only when they are in a noisy environment, or they may have
problems distinguishing sounds from different sources. They may not be
able to hear in one ear or both. Any difficulty with hearing that they
consider a problem should be captured.

B. Definition/s

[Hearing]{.underline} refers to an individual using his/her ears and
auditory (or hearing) capacity in order to know what is being said to
them or the sounds of activity, including danger that is happening
around them.

C. Instructions

Two versions of the questions are provided; one for self-respondents and
one for proxy respondents. A proxy respondent (i.e. a close family
member) may be needed if the respondent is not able to answer for
themselves. Note if the person is wearing hearing aids, make sure that
they understand that the question refers to difficulties they may have
even while they are wearing their hearing aids.

Instructions relative to the answer categories are the same as for
question 1.

3.  **Do you have difficulty walking or climbing steps?**

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a.  **No- no difficulty**

b.  **Yes -- some difficulty**

c.  **Yes -- a lot of difficulty**

d.  **Can not do at all**

Alternative wording for proxy respondent:

3)  **Does {person} have difficulty walking or climbing steps?**

    a.  **No- no difficulty**

    b.  **Yes -- some difficulty**

    c.  **Yes -- a lot of difficulty**

    d.  **Can not do at all**

A. Objective

The purpose of this item is to identify persons who have some limitation
or problems of any kind getting around on foot. It may or may not
contribute to difficulty in doing their daily activities. They can have
a problem walking more than a block, or short or long distances, or the
problem can be that they can't walk up or down steps without difficulty.
They may not be able to walk any distance without stopping to rest or
they may not be able to walk without using some type of device such as a
cane, a walker or crutches. In some instances they may be totally unable
to stand for more than a minute or two and need a wheelchair to get from
place to place. Difficulties walking can include those resulting from
impairments in balance, endurance, or other non-musculoskeletal systems.
Any difficulty with walking (whether it is on flat land or up or down
steps) that they consider a problem should be captured.

B. Definition/s

[Walking]{.underline} refers to an individual using his/her legs in such
a way as to propel themselves over the ground to get from point A to
point B. The capacity to walk should be without assistance of any device
or human. If such assistance is needed, the person has difficulty
walking.

C. Instructions

Two versions of the questions are provided; one for self-respondents and
one for proxy respondents. A proxy respondent (i.e. a close family
member) may be needed if the respondent is not able to answer for
themselves. Note if the person is using an assistive device or has a
person to help them with this function, it is highly likely they have
difficulty with walking.

Instructions relative to the answer categories are the same as for
question 1.

4.  **Do you have difficulty remembering or concentrating?**

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a.  **No -- no difficulty**

b.  **Yes -- some difficulty**

c.  **Yes -- a lot of difficulty**

d.  **Cannot do at all**

Alternative wording for proxy respondent:

4)  **Does {person} have difficulty remembering or concentrating?**

    a.  **No -- no difficulty**

    b.  **Yes -- some difficulty**

    c.  **Yes -- a lot of difficulty**

    d.  **Cannot do at all**

A. Objective

The purpose of this item is to identify persons who have some problems
with remembering or thinking that contribute to difficulty in doing
their daily activities. They can have a problem finding their way
around, or the problem can be that they can't concentrate on what they
are doing, or they may forget where they are or what month it is. They
may not remember what someone just said to them or they may seem
confused or frightened about most things. Any difficulty with
remembering, concentrating or understanding what is going on around them
that they or family members (if the family member is the respondent)
consider a problem should be captured. We do not intend to capture
difficulties remembering or concentrating because of common everyday
situations such as high workload or stress, or as a result of substance
abuse.

B. Definition/s

[Remembering]{.underline} refers to an individual using his/her memory
capacity in order to recall what has happened around them. It means the
individual can bring to mind or think again about something that has
taken place in the past (either the recent past or further back). In
connection with younger people, remembering is often associated with
storing facts learned in school and being able to retrieve them when
needed.

[Concentrating]{.underline} refers to an individual using his mental
ability to accomplish some task such as reading, calculating numbers,
learning something. It is associated with focusing on the task at hand
in order to complete the task. It is the act of directing ones full
attention to one subject or to focus without distraction on one thing.

C. Instructions

Two versions of the questions are provided; one for self-respondents and
one for proxy respondents. A proxy respondent (i.e. a close family
member) may be needed if the respondent is not able to answer for
themselves. This is particularly true if the respondent has severe
problems with remembering or concentrating.

Instructions relative to the answer categories are the same as for
question 1.

# [Additional Questions]{.underline}:

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

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a.  **No -- no difficulty**

b.  **Yes -- some difficulty**

c.  **Yes -- a lot of difficulty**

d.  **Cannot do at all**

Alternative wording for proxy respondent:

5)  **Does {person} have difficulty (with self-care such as) washing all
    over or dressing?**

    a.  **No -- no difficulty**

    b.  **Yes -- some difficulty**

    c.  **Yes -- a lot of difficulty**

    d.  **Cannot do at all**

A. Objective

The purpose of this item is to identify persons who have some problems
with taking care of themselves independently. Washing and dressing
represent tasks that occur on a daily basis and are very basic
activities.

B. Definition/s

[Washing all over]{.underline} refers to the process of cleaning one's
entire body (usually with soap and water) in the usual manner for the
culture. The washing activity includes cleaning hair and feet, as well
as gathering any necessary items for bathing such as soap or shampoo, a
wash cloth, or water.

[Dressing]{.underline} refers to all aspects of putting clothing or
garments on the upper and lower body including the feet if culturally
appropriate. Gathering clothing from storage areas (i.e. closet,
dressers), securing buttons, tying knots, zipping, etc., should be
considered part of the dressing activity.

C. Instructions

Two versions of the questions are provided; one for self-respondents and
one for proxy respondents. A proxy respondent (i.e. a close family
member) may be needed if the respondent is not able to answer for
themselves. Note if the person is using an assistive device or has a
person to help them with this function, it is highly likely they have
difficulty with self-care.

Instructions relative to the answer categories are the same as for
question 1.

6.  **Because of a physical, mental of emotional health condition, do
    you have difficulty communicating, (for example understanding others
    or others understanding you)?**

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a.  **No -- no difficulty**

b.  **Yes -- some difficulty**

c.  **Yes -- a lot of difficulty**

d.  **Cannot do at all**

Alternative wording for proxy respondent:

6)  **Because of a physical, mental of emotional health condition, does
    {person} have difficulty communicating, (for example understanding
    others or others understanding {him/her}?**

    a.  **No -- no difficulty**

    b.  **Yes -- some difficulty**

    c.  **Yes -- a lot of difficulty**

    d.  **Cannot do at all**

A. Objective

The purpose of this item is to identify persons who have some problems
with talking, listening or understanding speech such that it contributes
to difficulty in doing their daily activities. They can have a problem
making themselves understood, or the problem may be that they can't
understand people who talk to them or try to communicate with them in
other ways

B. Definition/s

[Communicating]{.underline} refers to a person exchanging information or
ideas with other people through the use of language. They may use their
voices for their exchange or make signs or write the information they
want to exchange. Communication can be interrupted at numerous places in
the exchange process. It may involve mechanical problems such as hearing
impairment or speech impairment, or it may be related to the ability of
the mind to interpret the sounds that the auditory system is gathering
and to recognize the words that are being used. The intention is not to
include communication problems due to non-native or unfamiliar language.

C. Instructions

Two versions of the questions are provided; one for self-respondents and
one for proxy respondents. A proxy respondent (i.e. a close family
member) may be needed if the respondent is not able to answer for
themselves. This is particularly true if the respondent has severe
problems with communicating. Difficulties due to the fact that the
language spoken is not one\'s mother tongue should be excluded when
rating this question.

Instructions relative to the answer categories are the same as for
question 1.

![](media/image1.png){width="6.0in" height="0.1in"}

**Extended question set: Question by question specifications**

This purpose of this annex is to indicate what is intended by each
question in the in the [extended set]{.underline}. Interviewers should
use this information when respondents request clarification about
specific questions and should refrain from offering their own
interpretations. \[Note: In instances where the extended questions
represent WHO-DAS questions, WHO-DAS specifications were used.\]

**[Vision]{.underline}**

**Do you have difficulty [seeing and recognizing a person you know about
7 meters (20 feet) away]{.underline}?**

Alternative wording for proxy respondent:

**Does {person} have difficulty [seeing and recognizing a person
{he/she} knows about 7 meters (20 feet) away]{.underline}?**

> The respondent should answer this question taking into account any
> assistive device (glasses or contact lenses) she may be using. The
> question refers to "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.

**Do you have difficulty [seeing and recognizing an object at arm's
length]{.underline} or in**

**reading?**

Alternative wording for proxy respondent:

**Does {person} have difficulty seeing and recognizing an object at
arm's length or in reading?**

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

**[Hearing]{.underline}**

**Do you have difficulty [hearing someone talking]{.underline} on the
other side of the room in a normal voice?**

Alternative wording for proxy respondent:

**Does {person} have difficulty [hearing someone talking]{.underline} on
the other side of the room in a normal voice?**

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

**Do you have difficulty [hearing what is said in a
conversation]{.underline} with one other person in a quiet room?**

Alternative wording for proxy respondent:

**Does {person} have difficulty [hearing what is said in a
conversation]{.underline} with one other person in a quiet room?**

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

**[Remembering and Concentrating]{.underline}**

**Do you have difficulty [concentrating]{.underline} on doing something
for [ten minutes]{.underline}?**

Alternative wording for proxy respondent:

**Does {person} have difficulty [concentrating]{.underline} on doing
something for [ten minutes]{.underline}?**

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.

**Do you have difficulty [remembering]{.underline} to do [important
things]{.underline}?**

Alternative wording for proxy respondent:

**Does {person} have difficulty [remembering]{.underline} to do
[important things]{.underline}?**

This is a question about memory for matters of day to day importance. It
does not refer to memory for irrelevant content nor does it refer 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 cueing from personal assistants is *usually* in place as a memory
aid, performance should be rated with this help taken into
consideration.

Communicating

**Do you have difficulty generally understanding what people say?**

Alternative wording for proxy respondent:

**Does {person} have difficulty 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.

**Do you have difficulty [starting and maintaining a
conversation]{.underline}?**

Alternative wording for proxy respondent:

**Does {person} have difficulty [starting and maintaining a
conversation]{.underline}?**

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, gesturing).
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.*

**Do others generally have difficulty understanding you?**

Alternative wording for proxy respondent:

**Do others generally have difficulty understanding {person}?**

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 he/she
experiences when trying to communicate with others.

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

**[Mobility]{.underline}**

**Do you have difficulty moving around inside your home?**

Alternative wording for proxy respondent:

**Does {person} have difficulty moving around inside {his/her} 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.

**Do you have difficulty [going outside]{.underline} of your
[home]{.underline}?**

Alternative wording for proxy respondent:

**Does {person} have difficulty [going outside]{.underline} of {his/her}
[home]{.underline}?**

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.

**Do you have difficulty [walking a long distance]{.underline} such as a
[kilometer]{.underline} \[or equivalent\]?**

Alternative wording for proxy respondent:

**Does {person} have difficulty [walking a long distance]{.underline}
such as a [kilometer]{.underline} \[or equivalent\]?**

Distances should be converted into local system of measurement where
necessary.

**Do you have difficulty [using your hands and fingers]{.underline},
such as picking up small objects or opening or closing containers?**

Alternative wording for proxy respondent:

**Does {person} have difficulty using {his/her} 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.

**[Self Care]{.underline}**

**Do you have difficulty [washing]{.underline} your [whole
body]{.underline}?**

Alternative wording for proxy respondent:

**Does {person} have difficulty [washing]{.underline} {his/her} [whole
body]{.underline}?**

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 "N/A" for not applicable.

**Do you have difficulty getting [dressed]{.underline}?**

Alternative wording for proxy respondent:

**Does {person} have difficulty getting [dressed]{.underline}?**

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.

**Do you have difficulty [feeding]{.underline} yourself?**

Alternative wording for proxy respondent:

**Does {person} have difficulty [feeding]{.underline}
{himself/herself}?**

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]{.underline} 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).

**Do you have difficulty staying [by yourself]{.underline} for a [few
days]{.underline}?**

Alternative wording for proxy respondent:

**Does {person} have difficulty staying [by
{himself/herself}]{.underline} for a [few days]{.underline}?**

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 "N/A" is correct).

**Additional Questions**

**[Learning]{.underline}**

**Do you have difficulty [analyzing and finding solutions to
problems]{.underline} in day to day life?**

Alternative wording for proxy respondent:

**Does {person} have difficulty analyzing 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

**Do you have difficulty [learning]{.underline} a [new
task]{.underline}, for example, learning how to get to a new place?**

Alternative wording for proxy respondent:

**Does {person} have difficulty 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 is having difficulty answering, 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.

**[Interpersonal Interactions]{.underline}**

**Do you have difficulty [dealing]{.underline} with people [you do not
know]{.underline}?**

Alternative wording for proxy respondent:

**Does {person} have difficulty [dealing]{.underline} with people
{he/she} does [not know]{.underline}?**

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.

**Do you have difficulty [maintaining a friendship]{.underline}?**

Alternative wording for proxy respondent:

**Does {person} have difficulty [maintaining a
friendship]{.underline}?**

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 "N/A" for not applicable.

**Do you have difficulty [getting along]{.underline} with people who are
[close]{.underline} to you?**

Alternative wording for proxy respondent:

**Does {person} have difficulty [getting along]{.underline} with people
who are [close]{.underline} to {him/her}?**

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

**Do you have difficulty in [making new friends]{.underline}?**

Alternative wording for proxy respondent:

**Does {person} have difficulty in [making new friends]{.underline}?**

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 "N/A" for not
applicable.