Warwick-Edinburgh Mental Well
Contents
1. Thirty three item scale with 5 response categories Consists of statements covering appraisal expression and regulation of emotion in self and others and the utilisation of emotions in 24 problem solving Psychiatric Morbidity General Health Questionnaire 12 GHQ 12 Twelve item scale with 4 response categories A well established screening instrument designed to detect possible psychiatric morbidity in the general population Respondents are asked to respond to questions relating to their recent experience of anxiety self confidence ability to concentrate decision making capacity enjoyment of day today activities sleep disturbance and stress etc General Health EQ 5D thermometer A measure of health in general where respondents rate their overall health physical and mental on a 0 100 scale Responses to this scale tend to reflect physical more than mental health Response Bias Balanced Inventory of Desirable Responding BIDR Forty item scale split into two sub scales The first sub scale measures self deception SD the tendency to exaggerate certain responses or behaviours and the second sub scale measures impression management IM the tendency to over report desirable behaviours and under report undesirable behaviours 29 Appendix iii WEMWBS median scores across demographic groups population sample Combined HEPS Wave 12 and Well2. emotions This is expected because these two scales measure concepts that are separate from but not unrelated to positive mental health Internal consistency Considers whether the scale describes a consistent underlying theme in this case it considers the extent to which WEMWBS s items are focused on assessing mental well being Scores range from 0 to 1 and are measured by Cronbach s alpha coefficient The higher the co efficient the more highly correlated the items in the scale A coefficient of 0 7 0 8 is ideal Nunnally 1978 and higher coefficients may suggest that some degree of item redundancy exists in the scale Cronbach s alpha coefficient 0 89 n 348 This high coefficient suggests that while there is a good level of internal consistency there may be scope to reduce even further the number of items in the scale analyses are currently underway to explore the potential for a shortened scale see section 10 Test retest reliability Considers the stability of responses over a period of time Test retest reliability is determined by calculating the correlation between two sets of scores for the same group of people who repeat the test after a set period of time For WEMWEBS the time period was one week Correlation 0 83 after one week n 124 Intra class correlation coefficient The test retest reliability score was high for WEMWBS after one week This suggests that the transient fluctuations that
3. Those who commented on this manual Dr David Gordon NHS Health Scotland Emma Hogg NHS Health Scotland Kate O Hara CSIP West Midlands and Professor Stephen Platt University of Edinburgh Audience It is anticipated that the audience for this manual includes researchers and practitioners who are familiar with the use of scales in evaluations This manual does not seek to answer questions relating to what to consider for evaluation purposes For this the evaluation guides of NHS Health Scotland provide the required information and should be referred to in the first instance www healthscotland com mental health publications aspx Update revisions This manual will be updated and revised as necessary as further validation and data on WEMWBS become available For the current version at any time see http Awww healthscotland com scotlands health population Measuring positive mental health aspx 1 Previously known as the Scottish Executive Summary The Warwick Edinburgh Mental Well being Scale WEMWBS was developed by researchers at the Universities of Warwick and Edinburgh with funding provided by NHS Health Scotland to enable the measurement of mental well being of adults in the UK WEMWBS is a 14 item scale of mental well being covering subjective well being and psychological functioning in which all items are worded positively and address aspects of positive mental health The scale is scored by summing responses t
4. population under study can be compared with these provisional population norms to assess whether the level of mental well being is above or below this level Differences between the scores of different groups or between the scores of the same group of people at two points in time for example before and after an intervention need to be tested statistically using students t Test or equivalent to assess how likely the differences are to have arisen by chance At any given level of difference results are more likely to be significant if the groups being compared are large and less likely if the groups are small A sample size calculation needs to be carried out to assess how big a group should be to show statistical significance of a specific difference Table 6 gives examples of this for different sample sizes using WEMWBS data from the HEPS and Well surveys combined Table 6 Examples of sample size required Difference in WEMWBS scores between two groups Population size 1 points 2 points 3 points 5 points 10 000 1082 294 133 48 50 000 1184 301 134 48 100 000 1199 302 135 49 Sample size per group based on difference in mean scores of two groups using a power of 0 8 a significance level of 0 05 and population sample combined HEPS Wave 12 and Well 2006 datasets n 1 749 If groups within the sample are to be compared then the sample size calculation needs to be based on these groups for
5. think 2006 The third national Scottish survey of public attitudes to mental health mental wellbeing and mental health problems Scottish Executive Edinburgh To access the dataset contact Angela Hallam Angela Hallam scotland gsi gov uk Defra 2007 Sustainable development Indicators in your pocket 2007 An update of the UK Government Strategy indicators Department for Environment Food and Rural Affairs London Kammann R and Flett R 1983 Affectometer 2 A scale to measure current level of general happiness Australian Journal of Psychology 35 2 259 265 Gosling R Bassett C Gilby N Angle H and Catto S 2008 Health Education Population Survey Update from 2006 survey NHS Health Scotland Glasgow database on the Internet Colchester UK Data Archive 2007 Available from http Avww data archive sc uk Nunnally JC 1978 Psychometric Theory Second Edition McGraw Hill London Ryan RM and Deci EL 2001 On happiness and human potential a review of research on hedonic and eudaimonic well being Annual Review of Psychology 52 141 166 Scottish Government 2007 Scottish budget spending review 2007 The Scottish Government Edinburgh Tennant R Fishwick F Platt S Joseph S and Stewart Brown S 2006 Monitoring Positive Mental Health in Scotland Validating the Affectometer 2 Scale and Developing the Warwick Edinburgh Mental Well being Scale for the UK NHS Health Scotland Glasgow Tennant R Hille
6. 2006 Datasets Variable N Median 95 Cl p Total 1749 51 51 52 Sex Male 783 52 51 52 lt 0 05 Female 966 51 50 52 Age in years 16 24 176 53 52 53 lt 0 01 25 34 245 51 50 53 35 44 353 51 49 52 45 54 306 50 49 51 55 64 334 52 51 53 65 74 274 52 51 54 75 61 51 49 54 Tenure Own outright 523 52 52 53 lt 0 01 Own with a mortgage 705 52 51 52 Rent 519 50 49 51 Self perceived health status Very good 563 54 54 55 lt 0 01 Good 753 51 51 52 Fair 319 47 46 49 Poor 84 44 40 46 Very poor 29 41 36 47 Employment Status In work 968 52 51 52 lt 0 01 Student 82 52 50 54 Retired 465 51 50 52 Unemployed 154 49 47 51 Other 79 46 43 50 Marital Status Single 188 51 49 53 lt 0 01 Married Living as couple 418 52 51 53 Widowed Divorced Separated 155 49 46 51 Gross household income pa lt 5000 55 48 44 53 lt 0 01 5000 14999 198 49 47 51 15000 29999 180 53 51 54 30000 173 51 49 53 Terminal Education Age lt 16 228 52 50 53 lt 0 05 16 18 355 50 49 51 19 181 53 51 54 Chief Income Earner Social Grade A 38 55 51 57 lt 0 01 B 84 50 48 53 C1 217 51 50 53 C2 193 53 51 54 26 D 101 50 47 52 E 124 47 44 51 Tests conducted on a reduced set of individuals Variable only recorded in the HEPS survey 95 Cl 95 confidence interval of the median p value generated from a Kruskal Wallis test
7. Desirable Responding This contrasts with Affectometer 2 where self deception bias was a major disadvantage of the scale WEMWBS also performed better than three comparison mental health scales on impression management and better than two on self deception These findings suggest that both impression management and self deception response biases whilst still an issue as they are with all mental health scales are acceptable for monitoring and evaluation purposes at the group population level Focus groups Face validity Face validity assesses whether the items in the scale are suitable for the overall concept being measured For WEMWBS this was tested in two mini focus groups with members of the general population in England and Scotland selected on the basis of socioeconomic background age and sex Groups included mental health service users and non users Individuals were asked to complete WEMWBS and discuss their impressions of the scale The aim of these investigations was to test what people thought WEMWBS was designed to measure and to determine its user friendliness Participants were asked to identify any items which they thought irrelevant or confusing Results of these focus group discussions suggested that WEMWBS was clear user friendly and unambiguous Unlike the Affectometer 2 no suggestions were made to modify the scale or to clarify itin any way Importantly participants recognised that WEMWBS measured positive ment
8. J p value generated from a Jonckheere s tests for ordered alternatives test conducted excluding the Other category 27
9. Programme for Improving Mental Health and Well being commissioned by NHS Health Scotland developed by the University of Warwick and the University of Edinburgh and is jointly owned by NHS Health Scotland the University of Warwick and the University of Edinburgh 22 The Warwick Edinburgh Mental Well being Scale VEMWBS Below are some statements about feelings and thoughts Please tick the box that best describes your experience of each over the last 2 weeks STATEMENTS None of Rarely Some of Often All of the time the time I ve been feeling optimistic about the future I ve been feeling useful I ve been feeling relaxed I ve been feeling interested in other people I ve had energy to spare I ve been dealing with problems well I ve been thinking clearly I ve been feeling good about myself I ve been feeling close to other people I ve been feeling confident I ve been able to make up my own mind about things I ve been feeling loved I ve been interested in new things I ve been feeling cheerful Warwick Edinburgh Mental Well Being Scale WEMWBS NHS Health Scotland University of Warwick and University of Edinburgh 2006 all rights reserved 23 Appendix ii Description of scales used to assess the construct validity of WEMWBS Scales of affect feelings WHO Five Well being Index WHO 5 Five item scale of statements covering key mental affect states e g f
10. a person may experience from one day to the next are not reflected in the scores and these scores remain robust over a short period of time Response Bias Considers the extent to which an individual may tailor his or her responses in order to be perceived in a certain light a phenomenon known as impression management And also the extent to which an individual remains unaware of 6 their true state of mental well being known as self deception bias These two aspects of social desirability responding are measured using the Balanced Inventory of Desirable Responding BIDR Correlations between the two subscales of the Balanced Inventory of Desirable Responding and WEMWBS and between the two subscales and other mental health scales including Affectometer 2 are shown below Table 3 Correlation of WEMWBS to BIDR Impression Scale n Management Self Deception WEMWBS 115 0 18 0 35 Affectometer 2 115 0 25 0 55 WHO Five Well being Index 62 0 39 0 20 Positive and Negative Affect Scales 52 0 02 0 50 Positive subscale Positive and Negative Affect Scales 51 0 03 0 16 Negative subscale Satisfaction with life scale 62 0 34 0 40 Global life satisfaction scale 62 0 26 0 13 Pearson s correlation coefficient gt significant at 0 05 level gt significant at 0 01 level WEMWEBS showed a low correlation with both subscales of the Balanced Inventory of
11. example men separately from women and not on the total sample size ie the men plus women Dealing with missing data For the WEMWBS validation HEPS and Well responders were deleted if they were not full responders ie they did not answer all items of WEMWBS This harsh method was appropriate as the vast majority of responders were full responders and thus loss of sample size was minimal However it may be too harsh an approach to adopt in other surveys Views differ on how to deal with missing data and none of the possible methods have been assessed for WEMWBS The problem of missing data in multi item 16 scales is curiously under discussed in the methodological literature Some researchers use estimation to fill in missing values thus retaining their original sample size The following are noted as alternative methods to deleting respondents who are not full responders that have been suggested in literature e calculating the mean value of responses to items that a respondent has answered and then using that mean score as the score for those questions which that respondent did not answer e using the midpoint of the range of possible responses e using the mean response for the particular item from all respondents However using estimations to fill in missing values should only be done in situations where at least a certain proportion of items are answered If less than this proportion has been answered the respondent s scor
12. found by certain factors such as tenure employment status and marital status Non significant trends were found between mental well being and social grade with lowest scores among those in the most deprived groups a u shaped relationship was found for age and small but non significant differences were found for sex male scores were slightly higher Further research on WEMWBS is ongoing This includes establishing WEMWBS s sensitivity to change assessing its scaling properties and the potential to reduce the number of items and validation to determine whether WEMWEBS can be used with children aged 13 to 15 years of age Other research still required includes assessing the extent to which it is appropriate to use WEMWEBS to assess mental well being in English speaking ethnic minority populations in the UK As a short and psychometrically robust scale with no ceiling effects in population samples WEMWBS offers promise as a tool for monitoring mental well being at a population level It is freely available but prospective users should register with Dr Kulsum Janmohamed K janmohamed warwick ac uk or Professor Sarah Stewart Brown sarah stewart brown warwick ac uk If the scale is reproduced it must remain unaltered and include the copyright statement which appears with it Appendix ii ill Contents ee MRM CUICTION cx ro ces Ei eS con Ned ata Unleaded head an Gola 2 A word about mental Well DeiNG cceeeeseeeeeeeeeeee
13. of the time Some of the Time All of the time I ve been feeling optimistic about the future 1 3 I ve been feeling useful 1 I ve been feeling relaxed i I ve been feeling interested in other people I ve had energy to spare I ve been dealing with problems well I ve been thinking clearly I ve been feeling good about myself M IN N IN Ww _ ININ N GC uj o E a A I ve been feeling close to other people I ve been feeling confident _ I ve been able to make up my own mind about things i I ve been feeling loved I ve been interested in new things 4 I ve been feeling cheerful Scores o OIN MH IN Mw IN N R O o WO W w AB BA A A A BA A A A AR BS gt x5 30 Total Score 0 0 12 16 30 58 Presenting the results WEMWBS results should be presented as a mean score for the population of interest with either a standard deviation or 95 confidence interval The latter both provide a measure of variance of the scores in the population studied either as a whole or for sub groups within it The range of scores within a sample can also be presented Scores will vary between 14 and 70 Interpreting the results Table 4 page 14 shows that the average population mean is around 51 and that this varies according to the population group studied The mean score for the
14. that whilst it performed adequately it was longer than need be and subject to an unacceptable level of bias due to desirable responding respondents answering in a way they thought was likely to be approved of Tennant et al 2006 Tennant Joseph amp Stewart Brown 2007 A focus group study involving participants from a wide range of socio economic backgrounds found that although in general the scale was viewed favourably some of the items were considered to be difficult and in spite of the balance of positive and negative items the instrument was viewed predominantly as a measure of mental illness Tennant et al 2006 These results were reviewed by a multidisciplinary research advisory group familiar with epidemiological research as well as the academic literature relating to concepts of positive mental health The research team drafted a set of items derived partly from Affectometer 2 but taking into account the findings of the qualitative focus group research relating to difficult and potentially redundant items whilst at all times referring to current literature on positive mental health Working iteratively with members of the advisory group this new scale was refined to the 14 item scale WEMWBS 4 Validation of WEMWBS Validation to date has been performed in the UK with those aged 16 and above WEMWEBS was initially validated in student samples recruited at the universities of Warwick and Edinburgh in 2006 an
15. to determine whether the number of variables in the scale can be reduced e to determine the relationships between variables The test considers how much variance is added by each factor the scale considers The variance that each additional factor contributes is expressed by eigenvalues A scree plot of eigenvalues against component numbers can be used to illustrate the amount of variance that a single factor contributes 4 Figure 1 WEMWBS Scree Plot for student samples n 348 Scree Plot Eigenvalue N gt 5 6 7 8 9 101 Component Number Factor analysis confirmed a single underlying factor to the scale shown in the sharp elbow of the screen plot This underlying factor is interpreted to be mental well being Construct validity Considers the extent to which there are logical relationships between the scale and other scales or factors known to affect the concept being measured such as age or sex It is assessed by correlations between the scale under review and other scales measuring similar concepts convergent validity or different concepts divergent validity and by determining statistically significant differences in scale scores between different groups For the validation of WEMWBS this was assessed by testing correlations between WEMWBS and other scales that measure aspects of mental health as well as scales that measure general health and emotional intelligence Appendix ii and also the extent to whic
16. 9 2 48 2 50 2 19 181 51 8 50 7 52 9 Chief Income Earner Social Grade A 38 52 7 49 5 55 9 B 84 50 68 48 8 52 5 C1 217 51 5 50 5 52 6 C2 193 51 0 49 8 52 2 D 101 49 5 47 7 51 3 E 124 46 8 45 0 48 7 95 Cl 95 confidence interval of the mean In this large dataset small differences reach statistical significance meaning that the differences are likely to reflect real differences in the population Significant differences in mental well being were found for each of the five categories of self perceived health status ranging from very good to very poor For tenure those who rent were found to have significantly lower mental well being scores from those who own outright and own with a mortgage Those who were unemployed had significantly lower mental well being scores than those who were in work or studying although no significant differences were found between those who were retired compared to each of the other 4 employment categories For marital status those who were married or living as a couple had significantly higher mental well being then those who were categorised as single or as widowed divorced separated No real pattern was found for mental well being with respect to gross household income per annum or terminal education age There were no significant differences found either for chief income earner social grade gender or age although there appears to be a trend towards lower mental well be
17. GHQ 12 response categories being scored 0 0 1 1 was used p lt 0 01 see Figure 4 scatterplot and box and whisker plot The scatterplot left shows that respondents scoring the same on the GHQ 12 had a wide range of WEMWBS scores so although lower WEMWBS scores tend to be associated with higher GHQ 12 scores right one is not simply the inverse of the other The two scales are therefore not measuring the same thing 11 WEMWBS total score Figure 4 WEMWBS score vs GHQ 12 score scatter plot and box and 90 confidence interval whisker plot population sample a A i ie 2 3 i fo Q H H 3 a 4 eos 3 t n R E 4j H EE M so H H on 3 i o N WU Ss 3 2 e M Ss 2 3 4 5 8 E H tt T 3 1 2 3 4 td t p L9 GHQ 12 total score GHQ 12 total score Tennant et al Health and Quality of Life Outcomes 2007 5 63 doi 10 1186 1477 7525 5 63 12 7 Variation across demographic amp social groups Analysis of data from these two population surveys has also provided provisional population norms for WEMWBS across different socio demographic groups Table 4 below shows mean WEMWBS scores along with the lower and upper 95 confidence intervals and the number of responses on which these estimates are based Appendix iii shows the same analysis but for median scores and also contains significance p values The provisional population m
18. Warwick Edinburgh Mental Well being Scale WEMWBS User Guide Version 1 Professor Sarah Stewart Brown Professor of Public Health sarah stewart brown warwick ac uk amp Dr Kulsum Janmohamed Academic Clinical Fellow k janmohamed warwick ac uk Warwick Medical School University of Warwick Edited by Dr Jane Parkinson Public Health Adviser NHS Health Scotland June 2008 Acknowledgements The Warwick Edinburgh Mental Well being Scale was funded by the Scottish Government s National Programme for Improving Mental Health and Well being commissioned by NHS Health Scotland developed by the University of Warwick and the University of Edinburgh and is jointly owned by NHS Health Scotland the University of Warwick and the University of Edinburgh Acknowledgements go to the following Members of the research team involved in the development and validation of WEMWBS Ruth Fishwick University of Warwick Louise Hiller University of Warwick Professor Stephen Joseph University of Nottingham Professor Stephen Platt University of Edinburgh Professor Sarah Stewart Brown University of Warwick and Ruth Tennant University of Warwick Members of the research Advisory Group Professor Glynn Lewis University of Bristol Dr Jane Parkinson NHS Health Scotland Professor Jenny Secker Anglia Ruskin University Professor Stephen Stansfeld University of London and Professor Scott Weich University of Warwick
19. ach item is worded positively and together they cover most but not all attributes of mental well being including both hedonic and eudaimonic perspectives Areas not covered include spirituality or purpose in life These were deemed to extend beyond the general population s current understanding of mental well being and their inclusion was thought likely to increase non response WEMWBS aims to measure mental well being itself and not the determinants of mental well being which include resilience skills in relationship conflict management and problem solving as well as socioeconomic factors such as poverty domestic violence bullying unemployment stigma racism and other forms of social exclusion WEMWBS was developed through research that was conducted at Warwick and Edinburgh Universities The starting point for the research was a pre existing scale called the Affectometer 2 developed in the 1980s in New Zealand Kammann amp Flett 1983 Affectometer 2 consists of 20 statements and 20 adjectives relating to mental health in which positive and negative items are balanced It proved to have a broad measure of intuitive appeal to practitioners and researchers working in this area in the UK While it had been used ina number of countries there was no UK validation of the scale and so this validation was conducted as the first step in this research project Validation of the Affectometer 2 in both population and student samples suggested
20. al health rather than mental illness Scottish population samples n 1749 WEMWBS was included in the Autumn wave of the Scottish Health Education Population Survey HEPS 2006 wave 12 which collected data from a random sample of the Scottish population aged 16 to 74 on a wide range of aspects of health and health related lifestyles Gosling et al 2008 and also in the population survey Well What do you think Well 2006 conducted on a random sample of the Scottish population aged 16 and above to collect data on public attitudes to mental health mental well being and mental health problems Braunholtz et al 2007 Analysis of combined data from these two population surveys n 2075 for the combined datasets with complete WEMWBS scores for n 1749 and complete GHQ 12 scores for n 1239 have confirmed the findings of the student validation Tennant et al 2007 e verification of a pre hypothesised single underlying factor n 1749 e Cronbach s alpha 0 91 n 1749 again indicating that while there is a good level of internal consistency there may be scope to reduce the number of items in the scale even further e good performance against accepted criteria discriminating population groups largely as expected and in a way consistent with other population surveys see section 7 and Appendix iii e significant moderate negative correlation to the General Health Questionnaire 12 GHQ 12 see section 7 5 Dist
21. ation of changes in WEMWBS scores will confirm that the measure is sensitive to change Validation of WEMWBS with secondary school children aged 13 to 15 years Research began in March 2008 to establish whether WEMWBS can be used to assess the overall mental well being of children of secondary school age 13 to 15 years of age This is the Warwick Edinburgh Mental Well being Scale Acceptability and Validation in English and Scottish Secondary School Students project The WAVES Project being undertaken by Warwick and Edinburgh Universities This will report October 2011 Other research required Other research still required includes assessing the extent to which it is appropriate to use WEMWBS to assess mental well being among different ethnic 19 minority populations in the UK and other cross cultural validation for use of WEMWBS in countries other than the UK Further ahead As understanding of mental well being develops over the next decade it is likely that measurement scales will also need to evolve Whilst WEMWBS fulfils criteria for monitoring mental well being at present and represents a very significant step forward in terms of other currently available measures it is likely that it will need to undergo further development in the future This manual will be updated as results of the continuing validation of WEMWBS are known 20 Bibliography Braunholtz S Davidson S Myant K and O Connor R 2007 Well What do you
22. d subsequently discussed by two mini focus groups in Scotland and England Tennant et al 2006 Tennant et al 2007 WEMWBS was then included in two national Scottish population surveys in 2006 allowing validation using population data Table 1 below lists whether or not the psychometric tests involved in validating a scale have been performed on WEMWBS and if so the sample s used Details of the results are given on the following pages Table 1 Psychometric testing of WEMWBS Psychometric test Tested Sample Principal components factor analysis v enh aan ae E Student population samples amp Ponsrucrvaidiy i Scottish aig Sedain samples Internal consistency o Student population samples amp Scottish general population samples Test retest reliability v Student population samples Response Bias v Student population samples Si WEMWBS research advisory group amp Face or content validity v Focus groups Rasch analysis v Scottish general population samples Sensitivity to change X Currently being assessed Gold standard measure to assess Criterion validity X WEMWBS against does not currently exist Interest has been expressed in using c d WEMWBS in other countries An ross cultural validity x celandic version has been created by translation and back translation Student populations n 348 Principal components factor analysis The main aims in conducting these analyses were e
23. e should be set to missing Researchers do not agree on what the proportion should be For WEMWEBS it can be anticipated that estimations for more than three missing items is unlikely to be robust In such cases the WEMWBS score should therefore not be calculated and should be set as missing It will also be important to check the randomness of the missing data to ensure that certain items are not being systematically missed Overall however when dealing with missing WEMWEBS data it is important to note that the effect of using estimations for WEMWEBS scores has not been tested Using WEMWEBS in individuals WEMWEBS provides robust results for populations and groups It has not yet been validated for monitoring mental well being in individuals 17 9 Current usage of WEMWBS WEMWBS is currently being used in numerous surveys and intervention studies for example Surveys e Scottish Health Survey from 2008 e Scottish Prison Service 2007 Annual Prison Survey e British Social Attitudes Survey 2007 e HEPS Spring wave wave 13 2007 8 item version in Autumn wave wave 14 2007 e NHS Grampian population surveys e A large population survey in Iceland e National Childhood Development Study 2008 sweep e Under consideration for the Scottish Household Survey 2009 e Under consideration for the UK Household Longitudinal study 2009 e Under consideration for the Health Survey for England Local evaluations e Evaluations of local Arts
24. ean score is 50 7 with 95 confidence interval 50 3 51 1 from the combined HEPS wave 12 and Well 2006 datasets Table 4 WEMWBS mean scores across demographic groups population sample combined HEPS Wave 12 and Well 2006 datasets n 1 749 Variable n Mean 95 Cl Total 1749 50 7 50 3 51 1 Sex Male 783 51 3 50 6 51 9 Female 966 50 3 49 7 50 8 Age in years 16 24 176 51 7 50 6 52 8 25 34 245 50 1 49 1 51 1 35 44 353 49 7 48 8 50 7 45 54 306 49 5 48 4 50 5 55 64 334 51 4 50 4 52 4 65 74 274 52 4 51 3 53 4 75 61 51 2 48 9 53 4 Tenure Own outright 523 52 3 51 5 53 0 Own with a mortgage 705 51 1 50 5 51 7 Rent 519 48 6 47 8 49 4 Self perceived health status Very good 563 53 8 53 1 54 5 Good 753 50 9 50 4 51 9 Fair 319 47 6 46 6 48 6 Poor 84 43 5 41 3 45 6 Very poor 29 40 9 37 1 44 6 Employment Status In work 968 51 4 50 9 51 9 Student 82 51 8 50 2 53 4 Retired 465 50 6 49 8 51 4 Unemployed 154 48 4 47 0 49 8 Other 79 46 1 43 5 48 8 Marital Status Single 188 49 4 48 2 50 7 Married Living as couple 418 51 7 50 9 52 5 Widowed Divorced Separated 155 47 8 46 1 49 5 13 Gross household income pa lt 5000 55 48 3 46 0 50 6 5000 14999 198 48 3 46 9 49 7 15000 29999 180 52 3 51 1 53 5 30000 173 50 6 49 3 51 8 Terminal Education Age lt 16 228 50 7 49 5 51 9 16 18 355 4
25. eeeeeeeeeeeteeeeeeeeeeeenanees 3 What is WEMWBS and how was it developed cceeeeeseeeeeeeeeeenteees 4 Validation of WEMWBS a pbiccehe cos tecn sock ceced eecee e cabelas rucsecea faeeeneonareesea vee tne Student OPU AMON Secs ce ee ate te ee ee eels ee ee FOCUS JrOUDS ox set cetacean a teat naa eae tesla A EARE Scottish population samples caine eee eee hal e 5 Distribution of WEMWBS scores 02 200 cchercscee tects ecete cages tanecadeencnensieceentes 6 Comparison between WEMWBS scores and scores on the GHQ 12 7 Variation across demographic amp social QrOUPS ccceeeeeeeeeeeeeeeeeeeneees 8 Using VVEMW BSc cxcact xe opiates vensececessensiontyGod eae enone oromneieGpaem tank um beeen 9 Current usage Of WEMWBS ccccceeeesseeceeeeteeesseneeeeeeeeseaaeeeeeeeeneneeeees 10 Further validation research on WEMWBS 00 eeeceeeeeeeeeeeeeetteeeeeeeeeees Bibliography aie pene eee te rer ne eer eee Ore eee ne err ere Te ere arora errr Appendix i Conditions of using WEMWBG cecceeseeeeeeeeeteeeeeeeeeeeeenaaees Appendix ii Description of scales used to assess the construct validity of Appendix iii WEMWBS median scores across demographic groups MIE So oe aac at a ee eee nee 3 1 Introduction Practitioners of mental health promotion and public mental health have for many years recognised the need to focus their efforts on improving mental health as well as preven
26. elt cheerful calm vigorous and interested with 5 response categories All items positively worded Short Depression Happiness Scale SDHS Six item scale with 4 response categories focused on affect with balanced positive and negative items e g felt happy felt cheerless Positive and Negative Affect Scale PANAS Positive subscale PANAS P Negative subscale PANAS N Twenty item scale with 5 response categories comprising a list of positive and negative adjectives covering a wider variety of feelings than is usual in mental health scales e g ashamed attentive proud guilty and excited Scales of subjective well being Global Life Satisfaction Scale GLSS Single item scale with 4 point response category On the whole are you satisfied with your life Most commonly used measure of subjective well being Satisfaction with Life Scale SWLS Five item scale with 7 response categories Items cover positive statements e g in most ways my life is close to ideal The prototype measure of well being Psychological functioning Scales of Psychological Wellbeing SPW Fifty four item scale with 6 response categories assessing psychological functioning with subscales measuring autonomy self acceptance environmental mastery purpose in life personal growth and positive relations with others Emotional Intelligence Emotional Intelligence Scale EIS
27. gh Mental Well being Scale WEMWBS as part of the Mental Health Indicators Programme This manual is for those who want to use WEMWBS for monitoring and research purposes as well as for evaluations Those who require information on what to consider for evaluation are referred to the NHS Health Scotland evaluation guides in the first instance www healthscotland com mental health publications aspx Ceiling and floor effects these occur when many people score the maximum or minimum score on a scale Improvements or deteriorations in the assessed variable being measured cannot therefore be identified For example significant ceiling effects in a mental health scale used in a general population sample may mean that people who possess only moderately good mental health can achieve the highest possible score As a result the instrument cannot show improvements in mental health in the healthier portion of the population distribution NHS Health Scotland was commissioned by the Scottish Government s National Programme for Improving Mental Health and Well being www wellscotland info to establish a core set of national sustainable mental health and well being indicators for adults in Scotland www healthscotland com understanding population mental health indicators aspx 1 2 A word about mental well being A necessary starting point for the development of a new instrument is a clear understanding of the concept which it
28. h it follows anticipated patterns for age and sex Table 2 Correlation of WEMWBS to other scales Scale n Correlation with WEMWBS WHO Five Well being Index 79 0 77 Short Depression Happiness Scale 71 0 76 Positive and Negative Affect Scale 63 0 73 Positive Subscale Positive and Negative Affect Scale 63 0 55 Negative Subscale Satisfaction With Life Scale 79 0 72 Global Life Satisfaction Scale 77 0 55 Scale of Psychological Well being 63 0 73 EQ 5D Thermometer 72 0 42 Emotional Intelligence Scale 67 0 51 Pearson s correlation coefficient gt significant at 0 05 level gt significant at 0 01 level Correlations were moderately high between WEMWBS and the Scale of Psychological Well being Satisfaction with Life Scale Short Depression Happiness Scale Positive and Negative Affect Scale positive subscale and the WHO Five Well being Index These results were similar to those found between Affectometer 2 and these scales which is as expected given that Affectometer 2 was the starting point for research on the WEMWEBS scale These results indicate that WEMWBS covers both hedonic and eudaimonic aspects of mental well being WEMWEBS showed moderate to low correlations with the EQ 5D thermometer a measure of overall physical and emotional health and the Emotional Intelligence Scale a measure of the ability to accurately assess one s own and others
29. inal scale relate to one another This analysis permits an answer to the following question Is a score of 60 twice as good as a score of 30 A good fit to the Rasch model indicates that the scale has good scaling properties This means that a mean score of for example 44 can be taken to be twice as good as a mean score of 22 Rasch analysis can also be used to determine potential item redundancy ina scale and to assess whether a reduction in the number of scale items may be appropriate Initial indications suggest that it may be possible to develop a shortened seven or eight item version of WEMWBS which has more robust scaling properties than the full scale WEMWBS s sensitivity to change Several studies are ongoing to assess the sensitivity to change of WEMWBS For example WEMWBS is being used to audit the mental well being of people attending a psychiatric day hospital Changes on WEMWBS will be compared with patient and clinical assessments of mental health at the beginning and end of each patient s admission If WEMWBS scores change significantly in the direction indicated by clinical assessment sensitivity to change will be confirmed WEMWBS is also being used to assess mental well being in parents attending a range of parenting programmes in the UK before they embark on the programme and at the end of the programme These programmes have previously been shown to have a positive impact on parents mental health and demonstr
30. ing for lower social grades and a U shaped relationship for age These are the first results for WEMWBS and larger surveys are required before population norms are fully established The availability of data on WEMWBS from for example the Scottish Health Survey n 6 000 from 2008 will help in this respect 14 8 Using WEMWBS WEMWBS is free to use but permission needs to be sought Further information is included in Appendix i Data Collection To date WEMWBS has been administered in a self completion format This has been either via CASI computer assisted self interviewing whereby respondents are invited to enter their responses directly into the CAPI computer assisted personal interview machine Well survey and HEPS or by the self completion of paper formats of the scale student samples and focus groups WEMWBS can be assumed to be robust using either of these methods WEMWEBS has not been tested in interview situations where an interviewer reads out the items to respondents and fills in their responses for them We do not therefore know if WEMWBS is robust in these situations Scoring Each of the 14 item responses in WEMWBS are scored from 1 none of the time to 5 all of the time and a total scale score is calculated by summing the 14 individual item scores Table 5 The minimum score is 14 and the maximum is 70 Table 5 Example Scoring of WEMWBS with responses highlighted in green Statements None
31. is designed to measure In the past there has been considerable discussion and debate about the nature of positive mental health and well being Recently a reasonable level of consensus has emerged among both academics and among the public Mental well being is now largely accepted as covering two perspectives 1 the subjective experience of happiness affect and life satisfaction the hedonic perspective and 2 positive psychological functioning good relationships with others and self realisation the eudaimonic perspective The latter includes the capacity for self development positive relations with others autonomy self acceptance and competence Those wanting to understand more about this subject are referred to the large literature clearly described in Ryan and Deci 2001 There has been some discussion in the academic literature as to whether mental well being and mental illness represent two ends of a single spectrum single continuum model or two separate dimensions two continua or dual continua model The two continua model allows for the possibility that people who have mental illnesses can experience mental well being It reflects the finding that analysis of instruments covering both positive and negative mental health often suggests two correlated but independent underlying factors Possible explanations for these findings include issues relating to how psychiatric conditions are defined the fluctuating nature of mental il
32. lness and individuals interpretations and responses to positively and negatively worded items on mental health measurement scales Mental well being relates to a person s psychological functioning life satisfaction and ability to develop and maintain mutually benefiting relationships Psychological well being includes the ability to maintain a sense of autonomy self acceptance personal growth purpose in life and self esteem Staying mentally healthy is more than treating or preventing mental illness Mental illness is a term to encompass mental disorders these are illnesses which affect mood affect and the ability to function effectively and appropriately Hedonic perspective of well being focuses on the subjective experience of happiness affect and life satisfaction Eudaimonic perspective of well being focuses on psychological functioning good relationships with others and self realisation This is the development of human potential which when realised results in positive functioning in life and covers a wide range of cognitive aspects of mental health 3 What is WEMWBS and how was it developed The Warwick Edinburgh Mental Well being Scale WEMWBS comprises 14 items that relate to an individual s state of mental well being thoughts and feelings in the previous two weeks see Appendix i Responses are made ona 5 point scale ranging from none of the time to all of the time E
33. o each item answered on a 1 to 5 Likert scale The minimum scale score is 14 and the maximum is 70 WEMWBS has been validated for use in the UK with those aged 16 and above Validation involved both student and general population samples and focus groups People participating in studies of face validity found the scale clear unambiguous and easy to complete They volunteered the opinion that the scale measured mental well being Population scores on WEMWBS approximate to a normal distribution with no ceiling or floor effects making the scale suitable for monitoring mental well being in population samples The scale is not designed to identify individuals with exceptionally high or low positive mental health so no cut off has been developed analogous to a mental illness cut off on for example the GHQ 12 scale The provisional Scottish population mean score is 50 7 with a 95 confidence interval of 50 3 to 51 1 obtained from a combined national dataset comprising data from the Health Education Population Survey 2006 wave 12 and the Well What do you think 2006 survey Scores derived from the student and population samples show a single underlying factor interpreted to be mental well being with low levels of social desirability bias and expected moderate correlations with other scales of well being Scores for individuals are stable over a one week period In general population samples significant differences in WEMWBS scores were
34. on Prescription Services e Assessments of social prescribing projects e Evaluating the impact of parenting programmes on parents mental well being in the Parenting Interventions Evaluation of Pathfinders projects e Evaluation of Lottery funded projects in England Monitoring interventions e Monitoring mental well being among patients attending psychiatric day hospital e Occupation therapy interventions at a day hospital WEMWBS is also being used as a national indicator in the e Scottish Government s Strategic Outcome Indicators 2008 for the Scottish Government s performance framework to monitor the spending review Scottish Health Survey data from 2008 Scottish Government 2007 e Scottish mental health and well being indicator set Scottish Health Survey data from 2008 And is being considered by the Department for Environment Food and Rural Affairs DEFRS for one of its indicators of well being specifically positive mental health in its sustainable development indicators Defra 2007 18 10 Further validation research on WEMWBS Although the basic establishment of WEMWBS is now completed further research is being undertake in a number of areas as indicated below The scaling properties of WEMWBS Data from the HEPS wave 12 2006 and Well 2006 population surveys are being used to establish the extent to which WEMWBS fits the Rasch model This is a statistical procedure used to determine how the intervals in an ord
35. r L Fishwick R Platt S Joseph S Weich S Parkinson J Secker S and Stewart Brown S 2007 The Warwick Edinburgh Mental Well being Scale WEMWBS development and UK validation Health amp Quality of Life Outcomes 5 63 doi 10 1186 1477 7525 5 63 Tennant R Joseph S and Stewart Brown S 2007 The Affectometer 2 a measure of positive mental health in UK populations Quality of Life Research 16 4 687 695 21 Appendix i Conditions of Using WEMWBS We welcome the use of WEMWBS It is free to use but is copyrighted to NHS Health Scotland and the Universities of Warwick and Edinburgh Permission is required for use Dr Kulsum Janmohamed K Janmohamed Warwick ac uk working with Professor Sarah Stewart Brown at the University of Warwick is maintaining a register of use and is the person to contact when seeking such permission When you seek permission for use you should indicate how you are planning to use WEMWBS We ask that after use you feed back to Dr Janmohamed on how WEMWBS has performed Dr Janmohamed is also the person to contact should you have more questions regarding the scale and its use If the scale is reproduced it must include the copyright statement which appears below it and no changes to its wording response categories or layout must be made Any report regarding use of WEMWBS should include the following text The Warwick Edinburgh Mental Well being Scale was funded by the Scottish Government National
36. ribution of WEMWBS scores In both the student and population samples WEMWBS scores followed a roughly normal distribution with only a slight left skew Figure 2 WEMWBS can be used to calculate mean scores for different groups of people or for the same people at different time periods Mean scores can be compared using standard deviations and 95 confidence intervals Figure 2 Distribution of WEMWBS scores for the combined HEPS wave 12 and Well 2006 datasets n 1749 Mean 50 7 Std Dev 8 79 N 1 749 0 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 WEMWEBS Score Because WEMWBS scores show a roughly normal distribution WEMWBS can be expected to capture the full spectrum of positive mental health without floor or ceiling effects and be suitable both for monitoring trends over time and evaluating the effect of mental health promoting programmes or interventions However although several studies are now in progress it is important to note that at the time of writing this manual WEMWBS s sensitivity to change has not been demonstrated As Affectometer 2 is sensitive to change there is no reason to think that WEMWBS will not be 3 Median scores should be used if data collected are not normally distributed and mean scores if the data are WEMWBS scores followed a roughly normal distribution with a slight left skew As the distribution is so close to normal it is considered appropriate
37. ting mental illness Because of confusion relating to use of the term mental health to describe services for people with mental illness terms like positive mental health and mental well being have been adopted to describe these initiatives Positive mental health and mental well being are used interchangeably in this manual Efforts to promote mental well being have been hampered by a lack of valid instruments which are suitable for measuring these attributes in the general population The monitoring of population mental well being and the evaluation of interventions to promote positive mental health has therefore had to be undertaken using instruments designed primarily to detect mental illness There are two problems with such an approach First mental illness measures tend to have significant ceiling effects in general population samples meaning that people with only moderately good mental health can achieve the highest possible score As a result the instrument cannot show improvements in mental health in the healthier portion of the population distribution Second participants who are involved in the evaluation of interventions to promote mental health may develop the erroneous impression that the interventions are designed only to help people with mental health problems and in this way the evaluation can affect the impact of interventions To overcome these problems NHS Health Scotland commissioned the development of the Warwick Edinbur
38. to use mean scores although some statisticians may decide that median scores should be used 9 As well as not being designed to identify people who have or probably have a mental illness WEMWBS does not a have a cut off level to divide the population into those who have good and those who have poor mental well being in the way that scores on other mental health measures for example the GHQ 12 do see section 6 10 6 Comparison between WEMWBS scores and scores on the GHQ 12 Both the HEPS and Well surveys included the GHQ 12 measure alongside WEMWEBS allowing the two to be compared in the same group of people As Figure 3 shows GHQ 12 scores are heavily skewed in population samples with the majority of people scoring 0 no evidence of possible mental illness This contrasts with the distribution of WEMWBS scores Figure 2 Because of this distribution GHQ 12 scores are more appropriately analysed in groups representing different levels of mental illness A cut off score of 4 is often used with the 4 group being more likely to have a diagnosable mental illness Figure 3 Distribution of GHQ 12 scores for the combined HEPS wave 12 and Well 2006 datasets n 1 239 GHQ 12 score WEMWEBS scores showed a significant moderate negative correlation with GHQ 12 scores in this population r 0 53 p lt 0 01 Spearmans rank correlation which persisted when a dichotomous scoring method with the four
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