Ordinal scaling properties of the WHO-5 among young adolescents in Moldova and North Macedonia: a Mokken Scale Analysis

Piolanti, Antonio, Glasauer, Christina, Shenderovich, Yulia ORCID: https://orcid.org/0000-0002-0254-3397, Wienand, Dennis, Simon, Judit, Shimbov, Bojan and Foran, Heather M. 2026. Ordinal scaling properties of the WHO-5 among young adolescents in Moldova and North Macedonia: a Mokken Scale Analysis. Health and Quality of Life Outcomes 10.1186/s12955-026-02624-7

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Abstract

Background The World Health Organization Five Well-Being Index (WHO-5) is commonly applied to assess subjective well-being. However, evidence on its ordinal measurement properties among young adolescents, especially in low- and middle-income countries, is scant. In particular, there is a lack of studies that have comprehensively evaluated key Mokken model assumptions, including scalability, monotonicity and invariant item ordering. Evaluating these properties is important as they support the ordinal interpretation of WHO-5 scores and clarify whether the items form an invariant hierarchy. Methods Baseline data from the FLOURISH project, a multi-country study evaluating a family-focused prevention program in Moldova and North Macedonia, were used. The sample comprised 653 adolescents aged 10–14 years. The ordinal scaling properties of the WHO-5 were examined using Mokken Scale Analysis, a non-parametric item response theory approach. Specifically, overall and item-level scalability were evaluated using Loevinger’s H coefficients. Single monotonicity was evaluated by examining local decreases in item step response functions, while invariant item ordering was assessed by examining pairwise intersections between manifest item response functions. The accuracy of the estimated ordering was evaluated using the HT coefficient. Analyses were also conducted separately by gender and country. Results The WHO-5 demonstrated strong overall scalability (h = 0.53, 95% CI: 0.49–0.57), with item-level scalability coefficients ranging from 0.50 to 0.56. Analyses revealed only minor and infrequent deviations from single monotonicity, with all diagnostic values below established thresholds. In addition, no meaningful violations of the nonintersection assumption were identified in the overall analysis. However, the HT coefficient was 0.12, indicating that the estimated item ordering was too inaccurate to be useful. Conclusions The findings corroborate evidence for the scalability and monotonicity of the WHO-5 and support the use of its summed score to distinguish adolescents with relatively lower or higher well-being at a given assessment, while cautioning against interpreting the group-level item ordering as a hierarchy that is accurately reproduced in individual adolescents’ response patterns.

Item Type:	Article
Date Type:	Published Online
Status:	In Press
Schools:	Schools > Social Sciences (Includes Criminology and Education) Schools > School of Social and Spatial Sciences Research Institutes & Centres > Centre For Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer) Research Institutes & Centres > Wolfson Centre for Young People's Mental Health (WCYPMH)
Publisher:	BioMed Central
ISSN:	1477-7525
Date of First Compliant Deposit:	3 September 2026
Date of Acceptance:	23 August 2026
Last Modified:	03 Sep 2026 15:45
URI:	https://orca.cardiff.ac.uk/id/eprint/189389

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