Reliability and Validity of World Health Organization Quality of Life-100 in Homeless Substance-Dependent Veteran Population

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INTRODUCTION

The increased focus on "recovery" of those with mental health diseases and addictions has moved attention away from solely symptom abatement. Important rehabilitation variables such as employment, housing, social relationships, and overall quality of life (QOL) are becoming important outcome variables for treatment. The homeless population encompasses many of these pressing needs. Though multiple definitions of homelessness exist, what is agreed upon is that homelessness is a significant problem that affects society. Numbers from the Urban Institute suggest that 3.5 million people experience homelessness during a given year [1]. The National Survey of Homeless Assistance Providers found that between 640,000 and 840,000, more than 10 percent of the nation's people living in poverty, were homeless on several predetermined nights [1]. Though astounding, the number of homeless veterans is disproportionately higher.

Numbers from the U.S. Department of Veterans Affairs (VA) CHALENG (Community Homelessness Assessment, Local Education, and Networking Groups) Report estimated that 194,254 U.S. veterans are homeless in any given year and veterans comprise approximately 20 to 30 percent of the homeless population [2]. The cost of caring for homeless veterans is high. In 2000, approximately $152 million were allocated to direct assistance for homeless veterans. This amount does not include incidental medical care secondary to a homeless lifestyle (e.g., dental care, effects of malnutrition, diabetes, and incidents related to exposure to elements).

Also of increasing concern is that returning veterans from Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) are at a high risk for homelessness because of their young age and limited job skills. Numbers from the Northeast Program Evaluation Center report that 9.5 percent of veterans in homeless Domiciliary Residential Rehabilitation and Treatment Programs (DOM-RRTPs) in fiscal year 2006 were from Persian Gulf war eras [3]. Further, VA numbers indicate that more than 73,000 of the 205,000 OIF/OEF veterans seeking VA services have possible mental health disorders, 34,000 with symptoms related to trauma. With the high association between mental illness and/or substance abuse and homelessness, the number of homeless veterans who served during the current conflicts will likely increase.

As a result of homeless veterans' desperate living conditions, the need for accurate assessment of QOL is most critical in this marginalized group. Accurate and appropriate measurement of QOL is critical to determining the effectiveness of programs. However, because of the multiple needs and program types for homeless individuals, tools are needed that can be used across different types of programs with different identified goals and that do not impose artificial criteria for success. Surprisingly, with the high cost of services and magnitude of the problem, little focus has been given in the United States to validating QOL instruments for this population.

The World Health Organization developed the World Health Organization Quality of Life-100 (WHOQOL100) [4-5] as a cross-cultural way of assessing QOL separate from a specific disease. Defining QOL as an "individual's perceptions of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns" [4], the WHOQOL-100 allows the respondent to determine his or her satisfaction while limiting constraints from cultural expectations or developer biases. Comprised of 100 items, the WHOQOL-100 is divided into 24 facets that make up 6 domains: Physical Capability, Psychological, Social Relationships, Environment, Independence, and Spirituality. Additionally, 4 items are used to create a Global Index.

The WHOQOL-100 was developed in 15 international centers through the use of item creation, focus groups, and field tests. …