PONE-D-24-60467Psychometric validation of an Arabic version of the WHO-5 wellbeing scale among Lebanese AdolescentsPLOS ONE

Dear Dr. El Khoury Malhame,

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this manuscript, which investigates the psychometric properties (i.e., factor structure, internal consistency, test-retest reliability, and convergent validity) of an Arabic version of the WHO-5 Well-Being Index among a sample of Lebanese adolescents.

I have three major concerns:

1. The study's contribution is somewhat unclear.

2. Previous psychometric findings of the WHO-5 in adolescent samples are not sufficiently discussed.

3. Some of the analyses could be expanded with more in-depth investigations.

Please see my detailed comments below.

Title: The scale is typically referred to as the "WHO-5 Well-Being Index" rather than "WHO-5 wellbeing scale". I recommend adjusting the title (and throughout the manuscript) accordingly to ensure accessibility for interested readers.

Abstract: In the abstract, write out "WHO-5 Well-Being Index" in full when first mentioned, followed by the acronym in parentheses (i.e., WHO-5).

Introduction

There is insufficient discussion of previous research on the psychometric properties of the WHO-5. Please provide more information on studies that employed adolescent samples. See for instance, Adjorlolo & Anum (2021), Allgaier et al. (2012), Blom et al. (2012), Cosma et al. (2022), and Sischka et al. (2025). Discussing these findings will help contextualize your study.

Methods

Closely adhere to survey reporting guidelines (e.g., Turk et al., 2018, supplemental material S2). The following methodological details should be specified:

- Data Collection Method: Was the survey conducted online or via postal mail?

- Survey Accessibility: If online, was it open to everyone or restricted (e.g., password-protected)?

- Recruitment Process: How was the survey advertised?

- Incentives: Were any offered?

- Question Requirements: If online, did the survey include mandatory questions (e.g., Sischka et al., 2022)?

- Item Order: If online, were the items randomized or presented in a fixed order?

How was the sample size determined? Please provide details regarding your sample size considerations (see Giner-Sorolla et al., 2024).

You wrote: "Students were asked about their age and gender, then filled out the validated, publicly available Arabic version of the standardized scales for well-being (WHO-5), depression (PHQ-9), and anxiety (GAD-7), in that order." If this version of the WHO-5 has already been validated (which aspects?), please provide references supporting this claim. Additionally, clarify what the contribution of the current study is.

You wrote “Some participants were tested twice for the same scales […]”. How were these participants selected? Was the second assessment available to all participants, or did only some opt to complete it?

In the Analytical Strategy section, you state: "There were no missing responses in the dataset." However, in the Participants section, you wrote: "The sample consisted of 701 high school students […]. Among those participants, 681 students had complete data and were included in the final sample […]." This suggests that missing data were handled through listwise deletion. If this is the case, please state it explicitly. As missing data can be effectively handled using full information maximum likelihood (FIML) in AMOS – which is widely regarded as a best-practice method (e.g., Newman, 2014) – I strongly recommend employing this approach instead.

The English WHO-5 response category reads as "At no time," but you wrote "Not at all." Please confirm whether this is an intended modification or a translation inconsistency.

Please include the Arabic translation of the WHO-5 (i.e., items, response categories, and instructions) in the manuscript.

Besides gender invariance, consider testing for age-group invariance as well.

Please specify how the latent variable was scaled in the CFA model (e.g., Little et al., 2006).

Add an explanation of the ICC in the Analytical Strategy section. Clearly specify which ICC coefficient was used, as different types exist with distinct assumptions and purposes (e.g., Aldridge et al., 2017).

Results

Consider providing local model fit information in addition to global fit statistics (e.g., Kline, 2024). This would also allow for comparison with previous WHO-5 psychometric studies, many of which have reported high correlated residuals for items 1 and 2.

Would it be possible to calculate effect size measures for measurement invariance (e.g., Nye et al., 2019; Gun et al., 2020)?

Please calculate item-level test-retest reliability coefficients (e.g., DeSimone, 2015) to provide a more nuanced view of item stability over time.

Discussion

The Results section states McDonald’s Omega = .83, but the Discussion section states McDonald’s Omega = .93. Please verify and correct this inconsistency.

Minor points

- You wrote “Pearson test was used to correlate the WHO-5 scores with the other scales […]”. Please revise this to: "Pearson correlations were calculated to examine the association between the WHO-5 scores and the other scales."

- Please change the heading “Interclass Correlation” to “Intraclass Correlation”.

This study addresses an important topic, and the manuscript is generally well-structured. However, clarifying the study's contribution, ensuring consistency in reporting, and expanding key analyses (e.g., local model fit, test-retest at the item level, measurement invariance effect sizes) would significantly strengthen the paper. Additionally, adherence to survey reporting guidelines is crucial for transparency and reproducibility.

I appreciate the authors' efforts and look forward to seeing the revised version.

References

Adjorlolo, S., & Anum, A. (2021). Positive and negative psychosis risk symptoms among adolescents in Ghana. International Journal of Adolescence and Youth, 26(1), 307–320. https://doi.org/10.1080/02673843.2021.1933110

Aldridge, V. K., Dovey, T. M., & Wade, A. (2017). Assessing test-retest reliability of psychological measures. European Psychologist, 22(4), 207-218. https://doi.org/10.1027/1016-9040/a000298

Allgaier, A.-K., Pietsch, K., Frühe, B., Prast, E., Sigl-Glöckner, J., & Schulte-Körne, G. (2012). Depression in pediatric care: Is the WHO-Five Well-Being Index a valid screening instrument for children and adolescents? General Hospital Psychiatry, 34(3), 234–241. https://doi.org/10.1016/j.genhosppsych.2012.01.007

Blom, E. H., Bech, P., Högberg, G., Larsson, J. O., & Serlachius, E. (2012). Screening for depressed mood in an adolescent psychiatric context by brief self-assessment scales - testing psychometric validity of WHO–5 and BDI-6 indices by latent trait analyses. Health and Quality of Life Outcomes, 10(1), 149. https://doi.org/10.1186/1477-7525-10-149

Cosma, A., Költö, A., Chzhen, Y., Kleszczewska, D., Kalman, M., & Martin, G. (2022). Measurement invariance of the WHO–5 Well-Being Index: Evidence from 15 European countries. International Journal of Environmental Research and Public Health, 19(16), 9798. https://doi.org/10.3390/ijerph19169798

DeSimone, J. A. (2015). New techniques for evaluating temporal consistency. Organizational Research Methods, 18(1), 133-152. https://doi.org/10.1177/1094428114553061

Giner-Sorolla, R., Montoya, A. K., Reifman, A., Carpenter, T., Lewis Jr, N. A., Aberson, C. L., ... & Soderberg, C. (2024). Power to detect what? Considerations for planning and evaluating sample size. Personality and Social Psychology Review, 28(3), 276-301.

Gunn, H. J., Grimm, K. J., & Edwards, M. C. (2020). Evaluation of six effect size measures of measurement non-invariance for continuous outcomes. Structural Equation Modeling, 27(4), 503-514. https://doi.org/10.1080/10705511.2019.1689507

Kline, R. B. (2024). How to evaluate local fit (residuals) in large structural equation models. International Journal of Psychology, 59(6), 1293-1306. https://doi.org/10.1002/ijop.13252

Little, T. D., Slegers, D. W., & Card, N. A. (2006). A non-arbitrary method of identifying and scaling latent variables in SEM and MACS models. Structural Equation Modeling, 13(1), 59-72. https://doi.org/10.1207/s15328007sem1301_3

Newman, D. A. (2014). Missing data: Five practical guidelines. Organizational Research Methods, 17(4), 372-411. https://doi.org/10.1177/1094428114548590

Nye, C. D., Bradburn, J., Olenick, J., Bialko, C., & Drasgow, F. (2019). How big are my effects? Examining the magnitude of effect sizes in studies of measurement equivalence. Organizational Research Methods, 22(3), 678-709.

Sischka, P. E., Martin, G., Residori, C., Hammami, N., Page, N., Schnohr, C., & Cosma, A. (2025). Cross-National Validation of the WHO-5 Well-Being Index Within Adolescent Populations: Findings From 43 Countries. Assessment. Advance online publication. https://doi.org/10.1177/10731911241309452

Sischka, P. E., Décieux, J. P., Mergener, A., Neufang, K. M., & Schmidt, A. F. (2022). The impact of forced answering and reactance on answering behavior in online surveys. Social Science Computer Review, 40(2), 405-425. https://doi.org/10.1177/0894439320907067

Turk, T., Elhady, M. T., Rashed, S., Abdelkhalek, M., Nasef, S. A., Khallaf, A. M., ... & Huy, N. T. (2018). Quality of reporting web-based and non-web-based survey studies: What authors, reviewers and consumers should consider. PloS one, 13(6), e0194239. https://doi.org/10.1371/journal.pone.0194239

Reviewer #2: Thanks for sending the paper. I see that this validations study is more focus on statistical basis (CFA). However, there are other forms of validity and reliability. Please see the paper.

Arafat, S. Y., Chowdhury, H. R., Qusar, M. M. A. S., & Hafez, M. A. (2016). Cross cultural adaptation and psychometric validation of research instruments: a methodological review. Journal of Behavioral Health, 5(3), 129-136.

Would you please check It??

Reviewer #3: I strongly suggest that the authors considers the addition of a descriptive table to show the sample profile, using variables of individual characteristics, such as gender, age, sexual orientation and grade level.

Regarding the analytic strategy, I strongly recommend the use of R or JASP to run the analysis. Furthermore, considering that the WHO-5 is a 6 point likert scale, I suggest to evaluate the multivariate normality assumption of SEM with Mardia’s test, and in case of violations in multivariate normality, I suggest to use the Weighted Least Squares Mean and Variance adjusted estimator (WLSMV), due to the ordinal nature of the items, instead of non-parametric bootstraps.

In the “Further analyses” topic, I suggest to use the Shapiro-Wilks or Kolmogorov-Smirnov test to assess the assumption of normality distribution, in order to use the t-test and the Pearson’s correlation index.

It seems that the authors know the relevance of assumptions of the statistical analysis, but the statistical procedure lacks on the correction of the violations of these assumptions.

The “Participants” topic is duplicated (it appears on methods and results), and it seems that this section in the “results” is referring to the test-retest reliability results. It’s strongly recommended to use the Student’s t test, Generalized Linear Models (GLM) or Mann-Whitney tests to compare groups, in order to assess whether the results are different between measurement times. The test-retest reliability can be tested using linear correlation between the results (pre and post), with strong correlations indicating good results.

In “confirmatory factor analysis of the WHO-5 scale”, the article mentions the composite reliability using the alpha and omega letters. It seems to be a typing error, these are not composite reliability indexes, but internal consistency indexes, and composite reliability is another one, calculated using factor loadings, it needs to be corrected.

Regarding the “gender invariance”, it’s not clear why to compare groups using t test by gender, since the factorial invariance is measured using CFA models, and not the general score of the instrument (table 2 is the correct for evaluating factorial invariance).

I suggest the authors to avoid very small topics, as interclass correlation and concurrent validity.

In the discussion, the authors mentions the “divergent validity”, but it's not clear how it was measured

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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PONE-D-24-60467R1Psychometric validation of an Arabic version of the WHO-5 wellbeing index among Lebanese AdolescentsPLOS ONE

Dear Dr. El Khoury Malhame,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 23 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Janna Metzler

Academic Editor

PLOS ONE

Additional Editor Comments:

Thank you for your revision. I've read through your response to reviewers and supporting documents. To better facilitate the review process, it would be helpful to add page and line numbers for the revision and directly cite the page/line numbers in your response. This will allow our reviewers to go directly and confirm the information stated in the response. At a minimum, the revision should include a tracked changes version indicating text changes (rather than highlighted in yellow in the submitted documents) would be preferable prior to proceeding with the review process.

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PONE-D-24-60467R2Psychometric validation of an Arabic version of the WHO-5 wellbeing index among Lebanese AdolescentsPLOS ONE

Dear Dr. El Khoury Malhame,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================The manuscript has been improved through changes made on the most recent revision. However, there are still methodological considerations (see Reviewer 1 comments) that require clarification prior to acceptance.Prior to acceptance, the manuscript should include the following changes: 1. The estimation methods must be clearly specified.2. Explicitly state the ICC model used and whether your aim was to assess consistency or absolute agreement.3. Clarify whether the internal consistency of each instrument cited in the manuscript were calculated using the current sample or drawn from previous studies.

==============================

Please submit your revised manuscript by Jul 15 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Janna Metzler

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to re-review this manuscript. Some aspects have been improved, but there are still several areas that require further consideration.

In the Methods section, three different CFA estimation methods are mentioned (i.e., WLSMV, maximum likelihood, robust maximum likelihood; p. 7, lines 5, 6, and 14). Please clarify which estimator was actually used and revise the description accordingly to accurately reflect your analytic procedure. Misreporting estimation methods can cause confusion and undermine the reproducibility of your results.

Regarding effect sizes, I was referring to measurement invariance effect sizes that indicate the magnitude of non-invariance (e.g., Gunn et al., 2020; Nye et al., 2019), not effect sizes for mean differences. That said, this was only a suggestion.

The phrase "two-way mixed-effect model ICC" is not specific enough to determine exactly which ICC type was used. SPSS provides several ICC variants under this model, depending on whether one is assessing single vs. average measures, and consistency vs. absolute agreement (see also Shrout & Fleiss, 1979). To enhance transparency and allow proper interpretation, please explicitly state the ICC model used (e.g., ICC(3,1)) and whether your aim was to assess consistency or absolute agreement. This level of detail is important for evaluating the reliability of the WHO-5 across time points.

Please also clarify whether the internal consistency estimates for the GAD-7 and PHQ-9 reported in the Measures section were calculated using the current sample, or if they were taken from previous studies. If the latter is the case, please additionally report the internal consistency values based on your current sample.

The manuscript should be thoroughly proofread, as some sentences remain awkwardly phrased and/or vague/ambiguous. A few examples:

- “However, some missing data was found in the other variables (age, gender, etc.) and were not replaced.” Please rephrase into something like “Some missing data were present in demographic variables such as age and gender. These missing values were not imputed and were handled using listwise deletion in the relevant analyses.”

- “Normality was not verified since the p value of the Shapiro-Wilk test turned out significant (p < 0.001).” Please rephrase into something like “The distribution of the WHO-5 scores was not normal, as indicated by a significant result from the Shapiro-Wilk test (p < .001).”

References

Aldridge, V. K., Dovey, T. M., & Wade, A. (2017). Assessing test-retest reliability of psychological measures: Persistent methodological problems. European Psychologist, 22(4), 207–218. https://doi.org/10.1027/1016-9040/a000298

Gunn, H. J., Grimm, K. J., & Edwards, M. C. (2020). Evaluation of six effect size measures of measurement non-invariance for continuous outcomes. Structural Equation Modeling, 27(4), 503-514. https://doi.org/10.1080/10705511.2019.1689507

Nye, C. D., Bradburn, J., Olenick, J., Bialko, C., & Drasgow, F. (2019). How big are my effects? Examining the magnitude of effect sizes in studies of measurement equivalence. Organizational Research Methods, 22(3), 678-709. https://doi.org/10.1177/1094428118761122

Shrout, P. E., & Fleiss, J. L. (1979). Intraclass correlations: Uses in assessing rater reliability. Psychological Bulletin, 86(2), 420–428. https://doi.org/10.1037/0033-2909.86.2.420

Reviewer #2: Psychometric validation of an Arabic version of the WHO-5 wellbeing index among Lebanese Adolescents" (PONE-D-24-60467R2)

Thanks

Reviewer #3: (No Response)

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes:  Julio Cezar Albuquerque da Costa

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<p>Psychometric validation of an Arabic version of the WHO-5 wellbeing index among Lebanese Adolescents

PONE-D-24-60467R3

Dear Dr. El Khoury Malhame,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Additional Editor Comments (optional): The following comments were provided by reviewer #1. Should you wish to edit the text further, do let me know. 

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: All comments have been addressed

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Reviewer #1: Yes

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Reviewer #1: Yes

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Reviewer #1: No

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Reviewer #1: Yes

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Reviewer #1: Thank you for the opportunity to re-review this manuscript. All remaining substantive comments have been adequately addressed, and I appreciate the authors’ thoughtful revisions. However, the manuscript would still benefit from a careful language review. Several sentences remain awkwardly phrased or imprecise, which affects readability. To improve clarity and polish, I strongly recommend a thorough language revision—ideally by a native English speaker or a professional academic proofreader. If that is not feasible, you may carefully use a language model such as ChatGPT (https://chatgpt.com/, see e.g., https://scitechedit.com/chatgpt-and-academic-writing/ point 4 and 5) to help revise the text. Please note that such tools should be used critically and cautiously—always reviewing the output to ensure it accurately reflects your intended meaning and maintains scientific precision. If you choose to use ChatGPT, I recommend revising the manuscript section by section using a prompt like the following: "Please help me revise the following section of an academic manuscript for grammar, clarity, and style. It should remain formal and scientifically accurate. Avoid changing the meaning, but feel free to rephrase awkward or unclear sentences. Here is the text: [Insert section here]."

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Reviewer #1: Yes:  Philipp E. Sischka

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