VETERANS RAND 36 ITEM HEALTH SURVEY (VR-36) Please do this: ● Instructions : This survey asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. Please answer every question by filling in one circle on each line. If you are unsure about how to answer a question, please give the best answer you can. 1. In general, would you say your health is: EXCELLENT VERY GOOD GOOD FAIR POOR 2. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? YES, LIMITED A LOT YES, LIMITED A LITTLE NO, NOT LIMITED AT ALL a. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports? b. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? c. Lifting or carrying groceries? d. Climbing several flights of stairs? e. Climbing one flight of stairs? f. Bending, kneeling, or stooping? g. Walking more than a mile? h. Walking several blocks? i. Walking one block? j. Bathing or dressing yourself? 3. During the past 4 weeks , have you had any of the following problems with your work or other regular daily activities as a result of your physical health? NO, NONE OF THE TIME YES, A LITTLE OF THE TIME YES, SOME OF THE TIME YES, MOST OF THE TIME YES, ALL OF THE TIME a. Cut down the amount of time you spent on work or other activities. b. Accomplished less than you would like c. Were limited in the kind of work or other activities. d. Had difficulty performing the work or other activities (for example, it took extra effort).
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VETERANS RAND 36 ITEM HEALTH SURVEY
(VR-36)
Please do this: l� Instructions: This survey asks for your views about your health. This information will help keep track
of how you feel and how well you are able to do your usual activities.
Please answer every question by filling in one circle on each line. If you are unsure about how to answer
a question, please give the best answer you can.
1. In general, would you say your health is:
�
EXCELLENT
�
VERY GOOD
�
GOOD
�
FAIR
�
POOR
2. The following questions are about activities you might do during a typical day. Does your health now
limit you in these activities? If so, how much?
YES,
LIMITED
A LOT
YES,
LIMITED
A LITTLE
NO, NOT
LIMITED
AT ALL
a. Vigorous activities, such as running, lifting heavy objects,
participating in strenuous sports?
� � �
b. Moderate activities, such as moving a table, pushing a
vacuum cleaner, bowling, or playing golf?
� � �
c. Lifting or carrying groceries? � � �
d. Climbing several flights of stairs? � � �
e. Climbing one flight of stairs? � � �
f. Bending, kneeling, or stooping? � � �
g. Walking more than a mile? � � �
h. Walking several blocks? � � �
i. Walking one block? � � �
j. Bathing or dressing yourself? � � �
3. During the past 4 weeks, have you had any of the following problems with your work or other regular
daily activities as a result of your physical health?
NO,
NONE
OF THE
TIME
YES,
A LITTLE
OF THE
TIME
YES,
SOME
OF THE
TIME
YES,
MOST
OF THE
TIME
YES,
ALL
OF THE
TIME
a. Cut down the amount of time you
spent on work or other activities.
� � � � �
b. Accomplished less than you would like � � � � �
c. Were limited in the kind of work or other
activities.
� � � � �
d. Had difficulty performing the work or other
activities (for example, it took extra effort).
� � � � �
4. During the past 4 weeks, have you had any of the following problems with your work or other daily
activities as a result of any emotional problems (such as feeling depressed or anxious)?
NO,
NONE
OF THE
TIME
YES,
A LITTLE
OF THE
TIME
YES,
SOME
OF THE
TIME
YES,
MOST
OF THE
TIME
YES,
ALL
OF THE
TIME
a. Cut down the amount of time you
spent on work or other activities.
� � � � �
b. Accomplished less than you would like. � � � � �
c. Didn’t do work or other activities as
carefully as usual.
� � � � �
5. During the past 4 weeks, to what extent has your physical health or emotional problems interfered
with your normal social activities with family, friends, neighbors, or groups?
�
NOT AT ALL
�
SLIGHTLY
�
MODERATELY
�
QUITE A BIT
�
EXTREMELY
6. How much bodily pain have you had during the past 4 weeks?
�
NONE
�
VERY MILD
�
MILD
�
MODERATE
�
SEVERE
�
VERY SEVERE
7. During the past 4 weeks, how much did pain interfere with your normal work (including both work
outside the home and house work)?
�
NOT AT ALL
�
A LITTLE BIT
�
MODERATELY
�
QUITE A BIT
�
EXTREMELY
8. These questions are about how you feel and how things have been with you during the past 4 weeks.
For each question, please give the one answer that comes closest to the way you have been feeling.
How much of the time during the past 4 weeks:
ALL
OF THE
TIME
MOST
OF THE
TIME
A GOOD
BIT OF
THE TIME
SOME OF
THE
TIME
A LITTLE
OF THE
TIME
NONE
OF THE
TIME
a. Did you feel full of pep? � � � � � �
b. Have you been a very
nervous person?
� � � � � �
c. Have you felt so down in
the dumps that nothing
could cheer you up?
� � � � � �
d. Have you felt calm
and peaceful?
� � � � � �
e. Did you have a lot of
energy?
� � � � � �
PLEASE CONTINUE èèèè
8. Continued from page 4…
How much of the time during the past four weeks:
ALL
OF THE
TIME
MOST
OF THE
TIME
A GOOD
BIT OF
THE TIME
SOME
OF THE
TIME
A LITTLE
OF THE
TIME
NONE
OF THE
TIME
f. Have you felt
downhearted and blue?
� � � � � �
g. Did you feel worn out? � � � � � �
h. Have you been a
happy person?
� � � � � �
i. Did you feel tired? � � � � � �
9. During the past 4 weeks, how much of the time has your physical health or emotional problems
interfered with your social activities (like visiting with friends, relatives, etc.)?
�
ALL OF
THE TIME
�
MOST OF
THE TIME
�
SOME OF
THE TIME
�
A LITTLE OF
THE TIME
�
NONE OF
THE TIME
10. Please choose the answer that best describes how true or false each of the following statements is for
you.
DEFINITELY
TRUE
MOSTLY
TRUE
NOT
SURE
MOSTLY
FALSE
DEFINITELY
FALSE
a. I seem to get sick a lot easier
than other people.
� � � � �
b. I am as healthy as anybody
I know.
� � � � �
c. I expect my health to get worse. � � � � �
d. My health is excellent. � � � � �
Now we’d like to ask you some questions about how your health may have changed.
11. Compared to one year ago, how would you rate your physical health in general now?
�
MUCH
BETTER
�
SOMEWHAT
BETTER
�
ABOUT THE
SAME
�
SOMEWHAT
WORSE
�
MUCH
WORSE
12. Compared to one year ago, how would you rate your emotional problems (such as feeling anxious,
depressed or irritable) now?
�
MUCH
BETTER
�
SOMEWHAT
BETTER
�
ABOUT THE
SAME
�
SOMEWHAT
WORSE
�
MUCH
WORSE
HOW TO SCORE THE VR-‐36 QUESTIONNAIRE
STEP1: SCORING QUESTIONS:
QUESTION NUMBER ORIGINAL RESPONSE RESPONSE ASSIGNED SCORE VALUE
Role limitations due to physical health 4 3a, 3b, 3c, 3d
Role limitations due to emotional problems 3 4a, 4b, 4c
Energy/fatigue 4 8a, 8e, 8g, 8i
Emotional well-being 5 8b, 8c, 8d, 8f, 8h
Social functioning 2 5, 9
Pain 2 6, 7
General health 5 1, 10a, 10b, 10c, 10d
�������
Contents
Feature 1Research Summary 3Initiatives 5Clinical Practice
Applications 7Research & Policy 9Health System
Improvement 11
�����
������
��� �
January 2000 Volume 5 Issue 1 A Publication for Members of Medical Outcomes Trust
The Veterans SF-36 Health StatusQuestionnaire: Development and Application inthe Veterans Health AdministrationLewis E. Kazis, Sc.D.
Dr. Kazis is Director of the Veterans SF-36 Project for the Office of Quality and Performance for theVeterans Administration, Washington, D.C. He is the Chief of Health Outcomes for the Center forHealth Quality, Outcomes and Economic Research, a Health Services Research and DevelopmentField Program, Veterans Administration Medical Center, Bedford, Massachusetts. He is alsoAssociate Professor of Health Services at the Boston University School of Public Health.
Use of a Generic Cost-Effectiveness Measure inVeterans Administration PatientsJeffrey M. Pyne, MD1
Robert M. Kaplan, PhD2
1 Dr. Pyne is Assistant Professor and Staff Physician, Department of Psychiatry, Central Arkansas VeteransHealthcare System and University of Arkansas for Medical Sciences, Little Rock, AR. He is supported by aVA Career Development Award.
2 Dr. Kaplan is Professor and Chair, Department of Family and Preventive Medicine, University of CaliforniaSan Diego, La Jolla, CA. He is also one of the principal developers of the Quality of Well-Being Scale.
Clinical Practice Applications continues on page 18Monitor, January 2000, volume 5, issue 1 8
Res
earc
h &
Po
licy
The New VA: Using Patient Outcomes to DriveHealth System PerformanceThomas L. Garthwaite, MD, MPH
Dr. Thomas L. Garthwaite was appointed Acting Under Secretary for Health in the Department of VeteransAffairs on July 1, 1999. In this capacity, Dr. Garthwaite is the highest official in the Veterans HealthAdministration.
Research and Policy continues on page 14Monitor, January 2000, volume 5, issue 1 10
Veterans Health
Hea
lth
Sys
tem
s Im
pro
vem
ent
Quality Outcomes of the PerformanceManagement Program in “The New VA”Jonathan Perlin, MD, PhD, MSHA
Dr. Perlin became Chief Quality and Performance Officer for the Veterans Health Administration (VHA) ofthe Department of Veterans Affairs on November 1, 1999. In this capacity, he has responsibility for support-ing quality improvement and the performance management program throughout VHA's 22 regional networkswhich operate over 170 medical centers, 650 other facilities including outpatient clinics, and 70 home-careprograms.
Editor’s Note: The accompanying article by Dr. Thomas Garthwaite, “The New VA: Using Patient Outcomesto Drive Health System Performance” describes the principles and challenges which undergird the transfor-mation process of the Veterans Health Administration (VHA) since 1995 and provide rationale for the com-prehensive Performance Management Program.
Breast Cancer Screening 91 70 73 134Cervical Cancer Screening 94 70 71 147Colorectal Cancer Screening 74 55 N/A 218Prostate Cancer Screening 66 N/A N/A >500
Substance Use:Alcohol Use 69 100 N/A >500Tobacco Use 95 100 N/A 194Smoking Cessation Counseling 93 100 63 266
*ftp://www.ncqa.org/docs/hedis/benchmk.docUS - United StatesPHS - Public Health ServiceHP 2000 Goals - Healthy People 2000NCQA - National Committee for Quality AssuranceHEDIS - Health Plan Employer Data & Information Set(%) - Percent successfully meeting goal
Validating the SF-36 health survey questionnaire: new outcomemeasure for primary care
J E Brazier, R Harper, N M B Jones, A O'Cathain, K J Thomas, T Usherwood, L Westlake
AbstractObjectives-To test the acceptability, validity,
and reliability of the short form 36 health surveyquestionnaire (SF-36) and to compare it with theNottingham health profile.Design-Postal survey using a questionnaire
booklet together with a letter from the generalpractitioner. Non-respondents received tworeminders at two week intervals. The SF-36 question-naire was retested on a subsample of respondentstwo weeks after the first mailing.Setting-Two general practices in Sheffield.Patients- 1980 patients aged 16-74 years randomly
selected from the two practice lists.Main outcome measures-Scores for each health
dimension on the SF-36 questionnaire and theNottingham health profile. Response to questions onrecent use of health services and sociodemographiccharacteristics.Results-The response rate for the SF-36 ques-
tionnaire was high (83%) and the rate of completionfor each dimension was over 95%. Considerableevidence was found for the reliability of the SF-36(Cronbach's a >0-85, reliability coefficient >0 75 forall dimensions except social functioning) and forconstruct validity in terms of distinguishing betweengroups with expected health differences. The SF-36was able to detect low levels of ill health in patientswho had scored 0 (good health) on the Nottinghamhealth profile.Conclusions-The SF-36 is a promising new
instrument for measuring health perception in ageneral population. It is easy to use, acceptable topatients, and fulfils stringent criteria of reliabilityand validity. Its use in other contexts and withdifferent disease groups requires further research.
Medical Care ResearchUnit and Department ofGeneral Practice,University of SheffieldMedical School, SheffieldS10 2RXJ E Brazier, lecturer in healtheconomicsR Harper, research associateN M B Jones, statisticianA O'Cathain, researchassociateK J Thomas, senior researchassociateT Usherwood, senior lecturerin general practiceL Westlake, statistician
Correspondence to:Mr Brazier.
BMJ 1992;305:160-4
IntroductionIt is important to be able to measure the perception
of health of the population to assess the benefit ofhealth care interventions and to target services.However, existing measures ofmortality and morbidityin the NHS are too narrow, particularly in generalpractice, to measure the benefit of interventions aimedat improving a wide range of dimensions includingmobility, functioning, mental health, and overall wellbeing. Researchers have developed measures to assessthe health of people with specific diseases or disabili-ties,"2 but these are of limited application whenstudying people with more than one condition orcomparing perceived health across different groups.What is required is a measure which is comprehensiveand sensitive to the full range of illness. To be ofpractical use the measure must also be brief and easy touse.One measure which is sensitive to health differences
in a general population has been developed out of the
Rand Corporation's health insurance experiment, acomprehensive evaluation of alternative methods offinancing health care in the United States.3 Theoriginal general health measure was lengthy, containing108 items. In an attempt "to develop a general healthsurvey that is comprehensive and psychometricallysound, yet short enough to be practical for use in largescale studies of patients in practice settings,"4 theauthors experimented with several shortened versions.The short form 20 has already been fielded with somesuccess in the medical outcomes study surveys in theUnited States' and in Scotland.6 However, the sub-stantially revised short form 36 health survey question-naire (SF-36) has yet to be independently validated inBritain. We examined the reliability and validity of theSF-36 in a British population, and compared it with theNottingham health profile,7 which is widely used inBritain.
MethodsThe SF-36 questionnaire is a self administered
questionnaire containing 36 items which takes aboutfive minutes to complete. It measures health on eightmulti-item dimensions, covering functional status,well being, and overall evaluation of health (table I).
TABLE I-Dimensions of the SF-36 health survey questionnaire
Area Dimension No of questions
Functional status Physical functioning 10Social functioning 2Role limitations (physical
problems) 4Role limitations (emotional
problems) 3Wellbeing Mental health 5
Vitality 4Pain 2
Overall evaluationof health General health perception 5
Health change* I
Total 36
*This item is not included in the eight dimensions nor is it scored.
Five of these dimensions are similar to those in theNottingham health profile, but items in the SF-36questionnaire are claimed to detect positive as well asnegative states of health.4 In six of the eight dimensionspatients are asked to rate their responses on three or sixpoint scales (box) rather than simply responding yes orno as in the Nottingham questionnaire. For eachdimension, item scores are coded, summed, andtransformed on to a scale from 0 (worst health) to 100(best health).We conducted face to face interviews using the
original American version of the SF-36 in a generalpractice surgery and among colleagues to examine itsacceptability. As a result the wording of six questionswas altered slightly. This anglicised version of the
BMJ VOLUME 305 18 JULY 1992160
SF-36 was incorporated into a booklet, together withthe Nottingham health profile and questions on socio-demographic characteristics and recent use of healthservices. We conducted a pilot postal survey of 120patients from a general practice list to test the accept-ability of mailing the booklet. We obtained a responserate of40% without reminders, with a good completionrate.The questionnaire booklet was sent to 1980 people
aged 16-74 years randomly selected from two generalpractice lists in Sheffield. It was accompanied by a
letter from the general practitioner, endorsing the aimsofthe study. Two reminder letters and further bookletswere sent to non-respondents at intervals oftwo weeks.To examine the retest reliability a copy of the SF-36
questionnaire was sent to 250 randomly selectedrespondents after two weeks.
STATISTICAL ANALYSIS
The responses to the questionnaire were subjected torecommended tests of reliability and validity.89 Theseare discussed in detail below.
Internal consistency is the extent to which itemswithin a dimension are correlated with each other. Itcan be examined by several methods: item to own
dimension correlations calculated after correction foroverlap; Cronbach's a, a widely used method based on
correlations between items; and reliability coefficientsfor each dimension calculated by two way analysis ofvariance.'0 We used non-parametric versions of thesetests to avoid any distributional assumption.
Test-retest reliability-A correlation coefficientmeasures the degree of association between the test andretest scores but does not indicate the direction of thisassociation. For example, if everyone consistentlyscored lower on the retest, the correlation coefficientwould be highly positive. To overcome this, Bland andAltman recommended a technique which examines thedistribution of differences in scores." The differencesare plotted, an overall mean and variance of differencescalculated, and 95% confidence intervals constructedaround the mean by assuming a normal distribution.The test and retest scores are assumed to be from thesame distribution when the differences have a mean ofzero and 95% of the differences lie within the 95%confidence limits.
Validity-The validity of a health measure is con-ceptually difficult to prove without a standard. Onemethod is to examine construct validity, wherehypotheses or constructs concerning the expecteddistribution of health between groups are examined bythe measure being validated.89 For example, women,older people, and people in social classes IV and Vmight be expected to perceive relatively poorer health;people making use of health services might also beexpected to have poorer perceived health than non-users. We used Kruskal-Wallis one way analysis ofvariance to test whether the SF-36 scores differedsignificantly among these groups. The convergent anddiscriminant validity of SF-36 was examined by themultitrait multimethod matrix. 12 For convergentvalidity, the correlation between comparable dimen-sions on SF-36 and Nottingham health profile-forexample, between physical functioning and physicalmobility-should be higher than the correlationsbetween less comparable dimensions-for example,physical functioning and social isolation. We testeddiscriminant validity by comparing item to own scalecorrelation with item to other scale correlation. Theitem to own scale correlation should be higher if thecategories within the SF-36 questionnaire are valid.
Discriminatory power-The ability of an instrumentto discriminate between different levels of ill health isstrictly a form of validity testing. We considered itseparately because it is a key criterion for any measureof general health in a population. Discriminatorypower is indicated by the frequency distributions ofscores obtained from the measures, with a less skeweddistribution indicating greater discriminatory power.A highly skewed distribution of scores requires use of abinary outcome whereas a wider range of scoresenables detection of intermediate health states.However, it should be confirmed that greater dis-criminatory power is genuine and correctly identifies illhealth.
ResultsWe received completed questionnaires from 1582 of
the 1980 patients surveyed, of whom 77 could not becontacted, thus giving a response rate of 83%. Of the250 patients sent a repeat test, 187 (75%) responded.The proportions of missing data from each dimensionwere lower (0 5%-4%) for the SF-36 questionnairethan for the Nottingham health profile (4-7%). Becauseso few data were missing for the SF-36 dimensions andthe study sample was large, we did not substitute formissing data. The extent of missing data was signifi-cantly associated (p<0-001) with increasing agein three of the eight SF-36 dimensions (pain, rolelimitations due to physical problems, and role limita-tions due to emotional problems).
CHARACTERISTICS OF SAMPLE
The sociodemographic characteristics and use ofhealth services of the respondents did not differ fromthose found in the general household survey (1988) forthe same age range, except for socioeconomic class,where the study sample included fewer people in classII but more in class III and more employed women.Too few patients from ethnic minorities were availableto permit separate analyses. Non-respondents in themain survey (n=297) were significantly more likely tobe male and younger in age and less likely to havevisited their general practitioner recently (p<0 005).
INTERNAL CONSISTENCY
Internal consistency was acceptable. The item toown dimension correlations, after correction foroverlap, exceeded 0 5 for all except three of the 33items. Cronbach's a exceeded the recommended
BMJ VOLUME 305 18 JULY 1992
Samples of questions from the SF-36
The following questions are about activities you might do during a typical day.Does your health limit you in these activities? If so, how much?
Yes, limited Yes, limited No, not limiteda lot a little at all
Climbing several flightsof stairs 0 0 0
Bending, kneeling, or 0 0 0stoopingWalking half a mile 0 0 0
These questions are about how you feel, how things have been with you during the pastmonth.How much time during the past month:
A goodAll of Most of bit of Some of A little of None of
the time the time the time the time the time the time
Did you feel full of life? Q 0 0 0 0 0Have you felt downheartedand low? 0 0 0 0 0 0
Has your health limitedyour social activities (likevisiting friends or closerelatives)? 0 0 0 0 0 0
161
minimum of 0859 and the reliability coefficients weregreater than 0 75 for all dimensions except socialfunctioning (a=0-73, reliability=0 74) (table II). Theresults for social functioning partly reflect the lownumber of items (two) in that dimension.
TEST-RETEST RELIABILITY AT TWO WEEKS
The re-test scores were highly correlated with thosefrom the main survey (table II). In the analysisrecommended by Bland and Altman" the mean of thedifferences was significantly different from zero for sixdimensions but did not exceed one point on the 100point scale, making it clinically insignificant (table II).For all dimensions 91-98% of cases lay within the95% confidence interval constructed for a normaldistribution.
TABLE iI-Reliability ofSF-36 questionnaire in general practice population
Table III shows the distributions of SF-36 scores bysex, age, social class, and use of health services and forpatients with chronic disease. The distribution ofscores conformed to what might be expected, thusproviding evidence of construct validity. Men per-ceived themselves to be significantly healthier thanwomen (p<0001), except on the general healthdimension. Significant age gradients were found forphysical functioning and pain (p<0 001), but little orno gradient was found for mental health (p=0 585).Health decreased with lower social class across alldimensions (p<005) except for general health per-ception. Those patients who had consulted a generalpractitioner in the previous two weeks had poorerperceived health than those who had not consultedrecently. Seventy seven patients for whom the generalpractitioner had diagnosed one or more chronicphysical problems perceived their health as worse onall dimensions (p<0001), except mental health, than asample of patients without chronic physical problemsmatched for age, sex, and general practice (p<005).The expected relations for convergent and dis-
criminant validity were mostly satisfied (table IV).Correlation coefficients for four comparable dimen-sions of the SF-36 questionnaire and Nottinghamhealth profile were higher than correlations betweennon-comparable dimensions. This was not found forthe correlation of social functioning with social
TABLE III-Mean scores on dimensions ofSF-36 questionnaire in relation to sociodemographic variables and use ofhealth services
Role RolePhysical Social limitation limitation Mental General health
Variable n* functioning functioning (physical) (emotional) Pain health Vitality perception
*Reliability coefficient. i-Correlation coefficients are negative because the two scales run in the opposite direction.
BMJ VOLUME 305 18 JULY 1992162
isolation, where the constituent questions seemed toaddress different aspects of social well being.
DISCRIMINATORY POWER
Comparison of the frequency distribution of SF-36scores and scores on the comparable dimensions of theNottingham questionnaire (figs 1 and 2) showed thatthe SF-36 scores were less skewed. The median scoresfor all Nottingham health profile dimensions were zero(good health) but were less than 100 (poorer health) onfive of the eight dimensions of the SF-36.
Table V shows the patients who scored zero on theNottingham questionnaire (good health) dividedaccording to those who scored 100 (good health) andthose who scored less than 100 (poorer health) on theSF-36 questionnaire (table V). The poorer healthgroup had a higher proportion ofwomen, had an older
40- Physical functioning I 00 - Physical mobility
30 - Soilfntoig 10 Soilislto
60 -
20 - 40
10 - 20--=-- 0-
10 25 450 65 90 100 95 75 50 35 10 0
70 - Sol functionings 00 Social isolation60 (physica80-50-~~~~~0
40 - 60
30- 4020 33.36EEI10 -10 - 20-
10 30 50 70 ~90 100 90 70 50 30 10O 0
80 - Role limitations
60 -(physical)
40-
20 -
0 33.33 66.67 100
Ojm - -mM12.5 37.5 62.5 87.5 100
FIG 1-Frequency distrtbution ofscores on SF-36 dimensions (left side)and comparable dimensions on the Nottingham health profile (rightside): functional status
50- Vitality 80- Energy
40- 60-
30-
20- 40-
10- 20-
12.5 37.5 62.5 87.5 100 87.5 62.5 37.5 12.5 0
Mental health 70- Emotional reactions30- 60-
~~50-I
20- 40-
5 3451 00- ii110- 20-
05 2545 6585 100 95 75 553515 0
40 100-
30- 80-
20-60-
10
20'5 25 45 65 85 100 95 75 55 35 15 0
25- General health
20 - perception15S-
5 25 45 65 85 100FIG 2-Frequency distribution ofscores on SF-36 dimensions (left side)and comparable dimensions on the Nottingham health profile (rightside): well being and overall health
mean age, and contained a higher percentage ofpatients not in full time employment than the goodhealth group. Patients in the poorer health group were
more likely to have consulted a general practitioner or
used outpatient services. These results were significantfor physical functioning, social functioning, and pain(p<005). The numbers of patients scoring 100 in theremaining two comparable dimensions (mental healthand vitality) were too few for significance to be shown.
DiscussionIn attempting to be comprehensive, existing general
health questionnaires such as the sickness impactprofile may be too long or require interviews, or both.'In primary care or community settings the contact timewith patients is often short, and thus to be practical and
TABLE v-Analysis of results for patients scoring zero on Nottingham health profile: comparison ofthose in good health (SF-36= 100) with thosescoring in poorer health (SF-36< 100) in relation to sociodemographic characteristics and use ofhealth services
% Visiting general % AttendingNo of Mean age Sex (% % Not full time practitioner in outpatients in % Inpatients in
Dimension score patients (years) female) employed previous 2 weeks previous 3 months past year
*p<0.05, **p<0.01, ***p<0.001, by yX test except for age (by Mann-Whitney U test)
BMJ VOLUME 305 18 JULY 1992 163
acceptable to the population the questionnaire must bebrief, easy to use, and preferably self administered.These features are also important for researchers, whomay want to add a generic health measure to a diseasespecific questionnaire. The SF-36 questionnaireseemed to meet these criteria, taking just five minutesto complete. We achieved a response rate of 83%, anddespite its presentation being more complex than thatof the Nottingham questionnaire there were fewermissing data. This quantitative evidence, and thefavourable impression for face to face interviews,suggests that the SF-36 questionnaire is an acceptablemeasure of the health of a general population.Our findings supported the developers' claims of
internal consistency for the SF-36 questionnaire.4 Thetest-retest reliability of the SF-36 questionnaire has notbeen examined before, and since an instrument with ahigh discriminatory power may be unreliable' itwas reassuring to find that test-retest reliability wasexcellent. The maximum mean difference in dimensionscores was 0-80, which implies that a person with a testscore of 70 might score 71 on retesting. This differenceis of no practical significance.The evidence for the construct validity of the SF-36
was substantial. The expected distribution of scoreswas observed by sociodemographic characteristics,general practitioner consultation, use of hospitalservices, and a group of patients with chronic physicalproblems.
COMPARISON WITH NOTTINGHAM QUESTIONNAIRE
In Britain many researchers,' and more recently theNHS,'3 have used the Nottingham health profile tostudy aspects ofhealth including rheumatoid arthritis,'4migraine,14 hypertension,'5 heart transplantation,'6renal lithotripsy,'7 and cholecystectomy."' It has alsobeen successfully applied in other countries.'920 Thequestionnaire takes just a few minutes to complete andis acceptable to the general population.7 However, ithas been criticised for tapping the extreme end of illhealth and therefore being unsuitable for examiningimprovements in health in a general population.' ' Ourresults strongly support this criticism-most of thegeneral population sampled registered a zero score onthe Nottingham dimensions, producing highly skeweddistributions. The distributions of SF-36 scores wereless skewed and showed a substantially higher pre-valence of perceived health problems, particularly withregard to mental health and vitality.By dividing patients who scored zero (good health)
on the Nottingham profile into those who scored 100(good health) or less than 100 (poorer health) on theSF-36 questionnaire we were able to identify peoplewith perceived health problems who were missed bythe Nottingham profile. The SF-36 questionnairetherefore seems preferable to the Nottingham profilefor measuring the health of a population with relativelyminor conditions, such as in general practice or thecommunity.
APPLICABILITY
The King's Fund is supporting several validationstudies looking at different patient groups to determine
whether the questionnaire is suitable for studyingspecific groups as well as the general population.Indications from unpublished work in the UnitedStates suggest that the SF-36 questionnaire could beused to study a wide range of serious conditions.However, the higher level of missing data for the 65-74year old age group in our study suggests that furtherresearch is required before it is widely applied toelderly patients. Measures such as the SF-36, whichproduce a profile of scores, can be criticised asunsuitable for comparisons between treatments thatmay improve the dimension scores differentially. Forthis purpose a single index of health is preferable andit is not yet known whether SF-36 scores can be used togenerate a valid single index. Existing measures whichpurport to provide single indices, such as the Yorkquality of life measure, have also yet to be validated.22
We thank our colleagues in the Department of GeneralPractice, Dr John Poyser, and Dr Helen Joesbury. The studywas supported by a grant from the Medical Research Council.The Medical Care Research Unit is funded by the DepartmentofHealth and Trent Regional Health Authority. The opinionsin this article are those of the authors.
I Wilkin D, Hallam L, Doggett MA. Measures of need and outcome for primarvhealth care. Oxford: Oxford Medical Press, 1992.
2 Bowling A. Measuring health: a reviezv of quality of life measurement scales.Milton Keynes: Open University Press, 1991.
3 Ware JE, Brook RH, Williams KN, Stewart AL, Davies-Avery A. Con-ceptualisation and measurement ofhealth for adults in the health insurance study.Vol 1. Model of health and methodology. Santa Monica, California: RandCorporation, 1980. (Publication No R-1987/1-HEW.)
4 Ware John E, Sherbourne CD. The SF-36 short-form health status survey. 1.Conceptual framework and item selection. Med Care (in press).
5 Stewart AL, Hays RD, Ware JE. The MOS short form general health survey.Med Care, 1988;26:724-35.
6 Anderson JStC, Sullivan F, Usherwood TP. The medical outcomes studyinstrument (MOSI)-use of a new health status measure in Britain. FamPract 1990;7:205-18.
7 Hunt S, McKenna SP, McEwen J. The Nottingham health profile user's manual.Manchester: Galen Research and Consultancy, 1989.
8 Streiner DL, Norman GR. Health measurement scales: a practical guide to theirdevelopment and use. Oxford: Oxford University Press, 1989.
9 McDowell I, Newell C. Measuring health: a guide to rating scales andquestionnaires. New York: Oxford University Press, 1987.
10 Kerlinger FN. Foundations of behavioural research. New York: Holt, Rinehart,and Winston, 1973.
11 Bland JM, Altman DG. Statistical methods for assessing agreement betweentwo methods of clinical measurement. Lancet 1986;i:307-10.
12 Campbell DT, Fiske DW. Convergent and discriminant validation by themultitrait-multimethod matrix. Psychol Bull 1959;56:81-105.
13 Final report: the CASPElFreeman outcome study. London: CASPE Research,1991.
14 Jenkinson C, Fitzpatrick R. The Nottingham health profile: an analysis of itssensitivity in differentiating illness groups. Soc Sci Med 1988;27:1411-4.
15 De Lame PA, Droussin AM, Thomson M, Verhaest L, Wallace S. The effectsof endopril on hypertension and quality of life. A large multi-center study inBelgium. Acta Cardiologica, 1989;44:289-302.
16 O'Brien BJ, Banner NR, Gibson S, Yacoub M. The Nottingham health profileas a measure of quality of life following combined heart and lungtransplantation. J Epideomiol Community Health 1988;42:232-4.
17 May N, Petruckevitch A, Snowdon C. Patients quality of life followingextracorporeal shock wave lithotripsy and percutaneous nepholithotomy forrenal calculi. Inlz Technol Assess Health Care 1990;6:631-40.
18 Milner PC, Nicholl JP, Westlake L, Williams BT, Birch S, Ross B, et al. TFheevaluation of lithotripsy as a treatment for gallstones: a randomisedcontrolled trial approach in England. J3ournal ofLithotripsy and Stone Disease1989;1: 122-32.
19 Wiklund I, Romanus B, Hunt SM. Reliability of the Swedish version of theNottingham health profile. Int Disabil Stud 1988;10:159-63.
20 Baum FE, Cooke RD. Community-health needs assessment: use of theNottingham health profile in an Australian study. Med J Aust 1989;150:581-90.
21 Kind P, Carr-Hill R. The Nottingham health profile: a useful tool forepidemiologists? Soc Sci Med 1987;25:905-10.
22 Carr-Hill R, Morris J. Current practice in obtaining the "Q" in QALYs: acautionary note. BM3 1991;303:699-701.