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multi-item-scale · reviewed 2026-07-12

WHO-5 Well-Being Index

Licence verified: 2026-07-12 · record reviewed: 2026-07-12 (pass two)

Identity

Version: WHO-5 (1998 version), the current standard short form derived from earlier WHO-10 and WHO-6/28-item well-being schedules

Structure: 5 items, each positively worded, referring to the previous two weeks, rated 0 (at no time) to 5 (all of the time); raw score 0 to 25 conventionally multiplied by 4 to give 0 to 100

Original citation: Bech P, Olsen LR, Kjoller M, Rasmussen NK (2003) Measuring well-being rather than the absence of distress symptoms: a comparison of the SF-36 Mental Health subscale and the WHO-Five Well-Being Scale. International Journal of Methods in Psychiatric Research 12(2):85-91. https://doi.org/10.1002/mpr.145 (the 1998 five-item version; consolidated evidence reviewed by Topp et al. 2015, https://doi.org/10.1159/000376585)

Steward / publisher: World Health Organization; the scale was developed under the WHO Regional Office for Europe and historically maintained by the Psychiatric Research Unit, Mental Health Centre North Zealand, Denmark (Bech and colleagues). Master versions and translations are distributed by WHO.

Licence status (verified 2026-07-12): Copyright World Health Organization 2024; the WHO-5 master version is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO). Document ref WHO/UCN/MSD/MHE/2024.1. Non-commercial use and adaptation permitted with attribution and share-alike; commercial (including employer/vendor) use requires WHO permission.
Source: https://cdn.who.int/media/docs/default-source/mental-health/who-5_english-original4da539d6ed4b49389e3afe47cda2326a.pdf

Constructs claimed

The WHO-5 is presented as a unidimensional measure of subjective psychological (hedonic) well-being over the preceding two weeks, tapping positive mood, vitality and general interest. It is a measure of the presence of positive well-being rather than of symptom burden, although its origin and much of its validation lie in depression screening. It is a generic well-being index, not a workplace-specific or organisational instrument; workplace studies adopt it unchanged as a general well-being outcome.

In the question bank: WHO-5: cheerful and in good spirits · WHO-5: calm and relaxed · WHO-5: active and vigorous · WHO-5: woke up fresh and rested · WHO-5: daily life filled with interesting things

Evidence

Deployment context caveat. WHO-5 originated and was validated substantially as a wellbeing and depression-screening measure in clinical and disease populations; workplace deployment is a different context, and its criterion evidence against organisational outcomes is absent. (applies to every property below)

Structural validity Highwell-establishedevidence form: canonical

indirectness see findings

The WHO-5 is predominantly unidimensional: a single well-being factor is recovered across a wide range of populations and languages. The anchoring systematic review concluded high clinimetric validity and treated the scale as a coherent single dimension (Topp 2015). One-factor structures have since been confirmed by confirmatory factor analysis in adolescents with type 1 diabetes (de Wit 2007), in type 1 and type 2 diabetes outpatients (Hajos 2013), in a Chinese university sample (Fung 2022), in Chinese type 2 diabetes patients (Du 2023), in a Sinhala community sample (Perera 2020), in a Bangla general sample (Faruk 2021) and in Portuguese adolescents (Carvalho 2025); principal component analysis in euthymic bipolar patients returned a single factor explaining 59.7% of variance (Bonnín 2017). Item response and Rasch analyses concur: the scale was unidimensional with no differential item functioning by age, sex or inpatient/outpatient status in schizophrenia spectrum disorders, although initial category disordering was only resolved by merging two middle response options (Nielsen 2023), and a nationwide Norwegian post-discharge sample found a one-factor solution explaining 71.7% of variance (Iversen 2025). A five-country clinimetric study (Italy, Poland, Denmark, China, Japan) using Mokken and Rasch analyses reported scalability coefficients ranging from 0.42 to 0.84 with most language versions fitting Rasch expectations, supporting unidimensionality across cultures (Carrozzino 2022). Two qualifications recur. First, in five-item models the RMSEA is frequently elevated (for example 0.23 in an Australian diabetes sample despite CFI 0.98 and loadings 0.78 to 0.92, Halliday 2017; elevated again in the Norwegian sample, Iversen 2025), an artefact of very low degrees of freedom rather than clear misfit. Second, and more substantively, in a 15-country adolescent study the full five-item WHO-5 did not achieve a good measurement model; a four-item version dropping the first item ('cheerful and in good spirits') was needed (Cosma 2022), a finding echoed by a Japanese child study that also set that item aside on cultural grounds (Adachi 2025).

Confidence note: High: many good-quality CFA/IRT studies, large total N, consistently unidimensional in adults, with a documented five-item-model RMSEA artefact and a contested first item in some adolescent/cross-cultural samples.

Convergent and discriminant validity Highwell-establishedevidence form: canonical

indirectness see findings

The WHO-5 correlates strongly and negatively with depression measures and positively with other well-being measures, as expected for a well-being index that shares variance with low mood. Against depression screeners and symptom scales it shows large negative correlations: r = -0.73 with the PHQ-9 in Australian adults with diabetes (Halliday 2017), r = -0.694 with the PHQ-9 and r = -0.610 with the Hamilton Depression Rating Scale in Chinese type 2 diabetes patients (Du 2023), and r = -0.67 with the CES-D in adolescents with type 1 diabetes (de Wit 2007); moderate-to-strong correlations of 0.55 to 0.69 with PHQ, diabetes-distress and SF-12 mental component scores were reported in diabetes outpatients (Hajos 2013). It relates very strongly to depression severity even after controlling for anxiety, supporting some discriminant separation from anxiety (Krieger 2013). Convergent evidence with positive constructs includes r = 0.542 with the Warwick-Edinburgh Mental Well-Being Scale alongside a smaller divergent r = -0.443 with perceived stress (Faruk 2021), and strong associations with life satisfaction and meaning in life against weaker links to physical health (Iversen 2025). Correlations are more modest against broader distress or family-function measures: r = -0.45 with the PHQ-9 and -0.56 with the Kessler K10 in a Sinhala sample (Perera 2020), and r = 0.35 with a family-function measure in older Peruvian adults (Del Pilar Diaz-Nunez P 2025). Convergent construct validity with well-being, self-efficacy and self-esteem measures was also supported in a Chinese sample (Fung 2022).

Confidence note: High: numerous studies, consistent direction and plausible magnitudes; discriminant evidence against anxiety is thinner than convergent evidence against depression.

Criterion validity: reference standard Moderatewell-establishedevidence form: canonical

indirectness see findings

Criterion validity is well established against one target, depression case status, and is essentially absent against organisational outcomes. As a depression screener the WHO-5 performs well: against structured diagnostic interviews or established depression scales, reported areas under the ROC curve cluster around 0.81 to 0.88 (AUC 0.87 in Australian diabetes adults, Halliday 2017; 0.823 against clinical interview in Iranian students, Ghazisaeedi 2021; 0.882 in Chinese healthcare students, Yang 2023; 0.838 in schizophrenia, Fekih-Romdhane 2024). Sensitivity and specificity depend heavily on the cut-off: a cut-off below 13 gave 0.79/0.79 while below 8 gave 0.44/0.96 in the same Australian sample (Halliday 2017), a cut-off below 50 (on the 0 to 100 metric) gave 0.79 to 0.88 sensitivity in Dutch diabetes outpatients (Hajos 2013) and 0.89/0.86 in adolescents with type 1 diabetes (de Wit 2007); the anchoring review summarised the scale as a sensitive and specific depression screen across fields (Topp 2015). Importantly, this criterion evidence was earned in diagnostic and clinical-population settings, which differ from workplace deployment where no diagnostic gold standard is applied. Against organisational and health outcomes proper (sickness absence, staff turnover, diagnosed conditions, productivity) no criterion-validity study was located in this pass; workplace papers instead report cross-sectional or prospective associations, for example poor WHO-5 well-being being more common with low workplace social capital (Gao 2014), with adverse psychosocial work factors across 34 European countries (Schütte 2014) and prospectively in France (Bertrais 2021), lower well-being among self-employed than salaried workers in small enterprises (Park 2025), and higher odds of poor well-being with lower-quality supervisor behaviour and workplace social capital across 35 European countries (Kizuki 2020). These are construct-relevant associations, not criterion validation against an organisational gold standard.

Confidence note: Moderate: criterion validity against depression is strong and consistent but almost entirely from clinical and disease populations; criterion validity against organisational outcomes is Absent (no such study located).

Criterion validity: organisational Absent (a finding about the literature)untestedevidence form: canonical

indirectness see findings

Organisational criterion evidence (sickness absence, turnover, performance, diagnosed conditions in a work context): see the criterion findings; graded from the pass-one record.

Confidence note: Moderate: criterion validity against depression is strong and consistent but almost entirely from clinical and disease populations; criterion validity against organisational outcomes is Absent (no such study located).

Internal consistency Highwell-establishedevidence form: canonical

indirectness see findings

Internal consistency is consistently good to excellent. Cronbach's alpha values cluster in the low-to-high 0.80s to low 0.90s across populations: alpha 0.90 in Australian adults with diabetes (Halliday 2017), 0.88 in Chinese type 2 diabetes patients (Du 2023), 0.82 in adolescents with type 1 diabetes (de Wit 2007), 0.83 in euthymic bipolar patients (Bonnín 2017), 0.85 in a Sinhala community sample (Perera 2020), 0.81 to 0.90 across three countries of nurses (Lara-Cabrera 2022), 0.80 in Portuguese adolescents (Carvalho 2025) and 0.80 in Arabic-speaking schizophrenia patients (Fekih-Romdhane 2024). Higher values around 0.91 to 0.94 appear in Iranian students (Ghazisaeedi 2021), a Norwegian post-discharge sample (Iversen 2025) and Chinese healthcare students (Yang 2023). Where reported, McDonald's omega agrees closely with alpha (omega 0.84 in Luxembourg adolescents, Brisson 2025; omega 0.86 to 0.91 in Japanese children, Adachi 2025; omega 0.908 to 0.935 in Chinese healthcare students, Yang 2023). A lower alpha of 0.75 was reported for the Bangla version (Faruk 2021). Coefficient omega was the reliability index in the updated German norms study (Kliem 2025).

Confidence note: High: many studies, large total N, alpha and omega both reported and consistently adequate to excellent across diverse populations.

Test-retest reliability Lowthin

indirectness see summary

Test-retest reliability is the weakest-evidenced reliability property for the WHO-5 and deserves explicit flagging: dedicated studies are few, intervals are short, and the single study designed specifically to estimate it raised a measurement-error concern. The one purpose-designed test-retest and measurement-error study, in Danish patients with type 1 diabetes using a median five-day interval, found an intraclass correlation of 0.87 (95% CI 0.82 to 0.90) but a large minimal detectable change of 18.56 points on the 0 to 100 scale, which the authors judged a larger measurement error than desirable and flagged for further research (Schougaard 2022). Other estimates are incidental to validation studies and mostly over about two weeks: Pearson r = 0.72 with ICC 0.82 over two weeks in a Sinhala sample (Perera 2020), r = 0.83 over ten days in euthymic bipolar patients (Bonnín 2017), a retest coefficient of 0.71 in the Bangla validation (Faruk 2021) and ICC 0.803 over about one week in Chinese healthcare students (Yang 2023). No UK-based or workplace-specific test-retest estimate was located in this pass, and intervals long enough to separate stability from genuine change in well-being are not represented.

Confidence note: Low: only one purpose-designed study (which itself flagged a large minimal detectable change), remaining estimates incidental with short intervals, none from workplace or UK samples.

Measurement invariance Moderatewell-establishedevidence form: canonical

indirectness see findings

Measurement invariance across sex and age is generally supported in adults, with more mixed results across countries and in adolescents. In adults, configural, metric and scalar invariance across sex, age and education was reported in a nationwide Norwegian post-discharge sample (Iversen 2025); invariance across gender and age was supported in the representative German norms study (Kliem 2025); configural, metric and scalar invariance across sex held in a Sinhala community sample (Perera 2020); and equivalence across sex was shown in older Peruvian adults (Del Pilar Diaz-Nunez P 2025) and cross-sex invariance in Arabic-speaking schizophrenia patients (Fekih-Romdhane 2024). In Chinese healthcare students the scale was invariant across eleven sociodemographic groupings and longitudinally over one week (Yang 2023). Strong measurement invariance across the presence or absence of a current major depressive episode was also demonstrated (Krieger 2013). Cross-national and adolescent evidence is more qualified. Across 15 European countries the five-item model did not achieve acceptable cross-country invariance in adolescents, and a four-item version was required for valid comparison (Cosma 2022); across 43 countries an IRT analysis found many item parameters non-invariant although overall differential test functioning was only modest (Sischka 2025). Full scalar invariance was reported across academic, birth-country, language, sex, socioeconomic and school subgroups in Luxembourg adolescents (Brisson 2025) and across age and gender in Japanese children (Adachi 2025). No study located in this pass tested invariance across occupational groups or between working and non-working populations.

Confidence note: Moderate: scalar invariance across sex and age is repeatedly demonstrated in adults and large adolescent samples, but cross-country invariance of the five-item form is contested and occupation-based invariance is untested.

Responsiveness and MIC Lowthinevidence form: canonical

indirectness see findings

Responsiveness is asserted more often than it is quantified with a defined minimal important change. The anchoring review concluded the WHO-5 is responsive and can serve as an outcome measure in controlled clinical trials, balancing wanted and unwanted treatment effects (Topp 2015), and a 2025 disease-area review across 552 studies reported that the scale detects treatment-related changes in well-being across many conditions (Domenech 2025). Direct workplace responsiveness evidence is limited to small intervention studies: a phase-II stress-preventive leadership intervention in a German hospital reported improved WHO-5 well-being over three months (Stuber 2022). A formal minimal important change for the WHO-5 was not located in this pass; the closest quantitative anchor is the measurement-error study's minimal detectable change of 18.56 points on the 0 to 100 scale, which is a distribution-based detectable-change threshold rather than an anchor-based minimal important change and was itself flagged as large (Schougaard 2022).

Confidence note: Low: responsiveness is supported qualitatively by two large reviews and small intervention studies, but a validated anchor-based minimal important change was not located, and workplace-specific responsiveness rests on small samples.

Populations, languages and norms

The WHO-5 has been translated into more than 30 languages and validated across an unusually broad range of populations (Topp 2015); a 2025 review catalogued its use across essentially all major disease areas in 552 studies (Domenech 2025). Validation samples located in this pass span general community adults (German, Kliem 2025; Sinhala, Perera 2020; Bangla, Faruk 2021), older adults (Bonsignore 2001; Del Pilar Diaz-Nunez P 2025), adolescents and children (43-country and 15-country adolescent studies, Sischka 2025, Cosma 2022; Luxembourg, Brisson 2025; Portugal, Carvalho 2025; Japan, Adachi 2025), diabetes populations (de Wit 2007, Hajos 2013, Halliday 2017, Du 2023), severe mental illness (Nielsen 2023, Fekih-Romdhane 2024, Bonnín 2017, Iversen 2025) and occupational groups (nurses, Lara-Cabrera 2022; medical educators, Chan 2022; European employees, Schütte 2014). Updated general-population norms exist for Germany (Kliem 2025). No UK-specific validation, UK normative benchmark or UK workplace norm was located in this pass; practitioners needing a UK reference distribution would be relying on non-UK norms, most directly the German representative norms, which is an indirectness limitation for a UK workplace audience.

Criticisms and controversies

Four themes recur in the critical literature. First, the identity of the construct: although marketed as a positive well-being index, the WHO-5's validation base is dominated by depression screening, and it correlates so strongly with depression measures (for example r = -0.73, Halliday 2017) that some authors treat it as effectively a measure of the severity of depression (Krieger 2013). This matters for a workplace registry: the scale's criterion evidence was earned in diagnostic and disease settings, so using it to screen a workforce is deploying a clinically validated instrument outside the diagnostic context in which that validity was established, without a diagnostic gold standard in play. Second, the first item ('cheerful and in good spirits') is repeatedly identified as problematic in cross-cultural and adolescent samples, to the point that a four-item WHO-4 has been proposed for valid cross-country adolescent comparison (Cosma 2022) and adopted on cultural grounds elsewhere (Adachi 2025). Third, cut-off scores for likely depression vary substantially between studies and populations (for example optimal cut-offs corresponding to different thresholds across Halliday 2017, Ghazisaeedi 2021, Du 2023, Fekih-Romdhane 2024), so no single cut-off transfers automatically to a new setting. Fourth, structural analyses frequently report an elevated RMSEA in the five-item model and occasional response-category disordering (Halliday 2017, Nielsen 2023, Iversen 2025), and floor effects on some items in low-well-being clinical samples (Iversen 2025). Measurement error over short retest intervals has been flagged as larger than desirable (Schougaard 2022).

References (36)

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  2. Domenech, Kasujee, Koscielny, et al. (2025). Systematic Review of the Use of the WHO-5 Well-Being Index Across Different Disease Areas. https://doi.org/10.1007/s12325-025-03266-9
  3. Bech P, Olsen LR, Kjoller M, Rasmussen NK (2003). Measuring well-being rather than the absence of distress symptoms: a comparison of the SF-36 Mental Health subscale and the WHO-Five Well-Being Scale https://doi.org/10.1002/mpr.145
  4. Bonsignore, Barkow, Jessen, et al. (2001). Validity of the five-item WHO Well-Being Index (WHO-5) in an elderly population. https://doi.org/10.1007/BF03035123
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  6. Hajos, Pouwer, Skovlund, et al. (2013). Psychometric and screening properties of the WHO-5 well-being index in adult outpatients with Type 1 or Type 2 diabetes mellitus. https://doi.org/10.1111/dme.12040
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  8. Ghazisaeedi, Mahmoodi, Arpaci, et al. (2021). Validity, Reliability, and Optimal Cut-off Scores of the WHO-5, PHQ-9, and PHQ-2 to Screen Depression Among University Students in Iran. https://doi.org/10.1007/s11469-021-00483-5
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Record notes

[Upgraded from v0.1 to v0.2 structure in pass two; criterion field split, licence re-verified 2026-07-12.] Overall confidence in the WHO-5 as a well-being measure is High for structural validity, internal consistency, convergent validity and breadth of populations/languages; Moderate for measurement invariance (adults yes, cross-country five-item form contested); Low for test-retest reliability and for responsiveness with a defined minimal important change; and effectively Absent for criterion validity against organisational outcomes and for UK-specific norms. Schema stress-test notes: (1) The schema's single 'criterion_validity' field forced two very different evidence states into one cell, namely strong criterion evidence against depression versus no located evidence against organisational outcomes (absence, turnover, diagnosed conditions). The maintainers reported both explicitly and graded to the audience's actual need, but a registry might benefit from separating clinical-criterion from organisational-criterion validity. (2) The WHO-5 versus WHO-4 question sits awkwardly: the WHO-4 is a proposed reduced form, not a separate instrument, and evidence about item 1 belongs partly under structural validity, partly under invariance, and partly under criticisms; The maintainers have cross-referenced rather than duplicated. (3) The clinical-origin caveat required by the brief cuts across identity, criterion validity and criticisms; The maintainers have stated it in each place rather than confining it to one field. (4) Licensing 'free to use' is well supported in the secondary literature but the maintainers did not retrieve a formal WHO licence document in the latest review pass; the claim rests on peer-reviewed statements, so the maintainers have qualified it accordingly. (5) No UK data of any kind (validation, norms, workplace) surfaced; for a UK workplace audience the entire evidence base is indirect on locale, which the maintainers have flagged under populations and as a downgrade rationale.