About the SF-36

The SF-36 Health Survey was developed for the Medical Outcomes Study, and has been tested and validated extensively.  (The SF-36 Health Survey is a registered trademark of the Medical Outcomes Trust, Inc., 20 Park Plaza, Suite 1014, Boston, Massachusetts 02116.)

The SF-36 was originally designed in the US to help understand  how the health care system affects health.  It is now has a much  wider application, being used to measure the general health of  populations as well as to compare the health of patients with  different medical conditions.  It is a general measure that is  intended to capture quality of life as well as whether an individual is  healthy or not.  The SF-36 is made up of 8 scales.  These cover  the ability to function and complete everyday activities, including  physical activities and social activities.  The scales also capture  well-being, such as energy or fatigue and mental health.

1. Ware JJ, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care 1992; 30:473-83.

   A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.

2. Brazier JE, Harper R, Jones NM, O'Cathain A, Thomas KJ, Usherwood T, Westlake L. Validating the SF-36 health survey questionnaire: new outcome measure for primary care. BMJ 1992; 305:160-4.

   OBJECTIVES--To test the acceptability, validity, and reliability of the short form 36 health survey questionnaire (SF-36) and to compare it with the Nottingham health profile. DESIGN--Postal survey using a questionnaire booklet together with a letter from the general practitioner. Non-respondents received two reminders at two week intervals. The SF-36 questionnaire was retested on a subsample of respondents two 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 the Nottingham health profile. Response to questions on recent use of health services and sociodemographic characteristics. RESULTS--The response rate for the SF-36 questionnaire was high (83%) and the rate of completion for each dimension was over 95%. Considerable evidence was found for the reliability of the SF-36 (Cronbach's alpha greater than 0.85, reliability coefficient greater than 0.75 for all dimensions except social functioning) and for construct validity in terms of distinguishing between groups with expected health differences. The SF-36 was able to detect low levels of ill health in patients who had scored 0 (good health) on the Nottingham health profile. CONCLUSIONS--The SF-36 is a promising new instrument for measuring health perception in a general population. It is easy to use, acceptable to patients, and fulfils stringent criteria of reliability and validity. Its use in other contexts and with different disease groups requires further research.

3. Aaronson NK, Acquadro C, Alonso J, Apolone G, Bucquet D, Bullinger M, Bungay K, Fukuhara S, Gandek B, Keller S, et al. International Quality of Life Assessment (IQOLA) Project. Quality of Life Research 1992; 1:349-51.

   The International Quality of Life Assessment (IQOLA) Project is a 4-year project to translate and adapt the widely used MOS SF-36 Health Survey Questionnaire in up to 15 countries and validate, norm, and document the new translations as required for their use in international studies of health outcomes. In addition to the eight-scale SF-36 health profile, the project will also validate psychometrically based physical and mental health summary scores, as well as health utility indexes incorporating SF-36 scales for use in cost-utility studies.

4. McHorney CA, Ware JJ, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical Care 1993; 31:247-63.

   Cross-sectional data from the Medical Outcomes Study (MOS) were analyzed to test the validity of the MOS 36-Item Short-Form Health Survey (SF-36) scales as measures of physical and mental health constructs. Results from traditional psychometric and clinical tests of validity were compared. Principal components analysis was used to test for hypothesized physical and mental health dimensions. For purposes of clinical tests of validity, clinical criteria defined mutually exclusive adult patient groups differing in severity of medical and psychiatric conditions. Scales shown in the components analysis to primarily measure physical health (physical functioning and role limitations-physical) best distinguished groups differing in severity of chronic medical condition and had the most pure physical health interpretation. Scales shown to primarily measure mental health (mental health and role limitations-emotional) best distinguished groups differing in the presence and severity of psychiatric disorders and had the most pure mental health interpretation. The social functioning, vitality, and general health perceptions scales measured both physical and mental health components and, thus, had the most complex interpretation. These results are useful in establishing guidelines for the interpretation of each scale and in documenting the size of differences between clinical groups that should be considered very large.

5. Garratt AM, Ruta DA, Abdalla MI, Buckingham JK, Russell IT. The SF36 health survey questionnaire: an outcome measure suitable for routine use within the NHS? BMJ 1993; 306:1440-4.

   OBJECTIVE--To assess the validity, reliability, and acceptability of the short form 36 (SF 36) health survey questionnaire (a shortened version of a battery of 149 health status questions) as a measure of patient outcome in a broad sample of patients suffering from four common clinical conditions. DESIGN--Postal questionnaire, followed up by two reminders at two week intervals. SETTING--Clinics and four training practices in north east Scotland. SUBJECTS--Over 1700 patients aged 16-86 with one of four conditions--low back pain, menorrhagia, suspected peptic ulcer, or varicose veins--and a comparison sample of 900 members of the general population. MAIN OUTCOME MEASURES--The eight scales within the SF36 health profile. RESULTS--The response rate exceeded 75% in the patient population (1310 respondents). The SF36 satisfied rigorous psychometric criteria for validity and internal consistency. Clinical validity was shown by the distinctive profiles generated for each condition, each of which differed from that in the general population in a predictable manner. Furthermore, SF36 scores were lower in referred patients than in patients not referred and were closely related to general practitioners' perceptions of severity. CONCLUSIONS--These results provide support for the SF36 as a potential measure of patient outcome within the NHS. The SF36 seems acceptable to patients, internally consistent, and a valid measure of the health status of a wide range of patients. Before it can be used in the new health service, however, its sensitivity to changes in health status over time must also be tested.

6. Hays RD, Sherbourne CD, Mazel RM. The RAND 36-Item Health Survey 1.0. Health Economics 1993; 2:217-227.

   Recently, Ware and Sherbourne published a new short-form health survey, the MOS 36-Item Short-Form Health Survey (SF-36), consisting of 36 items included in long-form measures developed for the Medical Outcomes Study. The SF-36 taps eight health concepts: physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, general mental health, social functioning, energy/fatigue, and general health perceptions. It also includes a single item that provides an indication of perceived change in health. The SF-36 items and scoring rules are distributed by MOS Trust, Inc. Strict adherence to item wording and scoring recommendations is required in order to use the SF-36 trademark. The RAND 36-Item Health Survey 1.0 (distributed by RAND) includes the same items as those in the SF-36, but the recommended scoring algorithm is somewhat different from that of the SF-36. Scoring differences are discussed here and new T-scores are presented for the 8 multi-item scales and two factor analytically-derived physical and mental health composite scores.

7. Anderson RT, Aaronson NK, Wilkin D. Critical review of the international assessments of health-related quality of life. Quality of Life Research 1993; 2:369-95.

   This paper reviews the international adaptation and use of generic health quality of life measures over the last several years, including the Nottingham Health Profile (NHP) the Sickness Impact Profile (SIP), the Medical Outcomes Short-Form 36 (MOS SF-36), the EuroQol, and Dartmouth COOP Charts. International work with disease or condition specific HRQL measures is exemplified with the European Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ), and the Spitzer Quality of Life (QL) Index. Progress towards cross national measurement equivalence in HRQL measures reported in the literature has been uneven. Results show that the development of language-adapted versions of HRQL measures to date have mostly concerned translation issues, within the context of independently conducted studies. Substantially less focus has been placed on psychometric equivalence across language versions necessary for coordinated international studies, such as multi-national clinical trials. However, this picture is rapidly changing with recent projects underway to develop and refine new or existing HRQL measures. Overall, the lack of prominent differences found between countries in ranking of health states in major HRQL measures supports the feasibility of developing internationally applicable HRQL instruments. Recommendations are made for additional data needed to better ascertain the degree of measurement equivalence developed in the various versions of each instrument reviewed. [References: 137]

8. Jenkinson C, Wright L, Coulter A. Criterion validity and reliability of the SF-36 in a population sample. Quality of Life Research 1994; 3:7-12.

   This study aimed to determine the criterion validity of the Short Form 36 health survey questionnaire (SF-36) in a large community sample, and to explore the instrument's internal consistency and validity in groups reporting different levels of ill-health. A postal survey was undertaken using a questionnaire booklet, containing the SF-36 and a number of other items concerned with lifestyles and illness. The questionnaire booklet was sent to 13,042 randomly selected subjects between the ages of 18-64 years, drawn from Family Health Services Authority (FHSA) computerized registers for Berkshire, Buckinghamshire, Northamptonshire and Oxfordshire. This paper is based upon the 9332 (72%) responses gained. Scores for the functional status and well-being scales of the SF-36 were used as outcome measures. The response rate for the questionnaire booklet was 72%. Internal consistency of domains was found to be high, both for the sample as a whole, and when broken down by specific subgroups. Criterion validity was assessed by comparing scores for the seven multi-item dimensions assessing functional status and well being with a single global health question. The global question was the first item of the SF-36 and asks respondents to evaluate their health 'overall'. Statistically significant trends were observed for decreasing SF-36 scores (i.e., those indicating greater health problems) with worsening self-rated general health. These results provide further psychometric evidence for the use of the SF-36 when used with groups reporting varying extents of ill-health.

9. McHorney CA, Kosinski M, Ware JJ. Comparisons of the costs and quality of norms for the SF-36 health survey collected by mail versus telephone interview: results from a national survey. Medical Care 1994; 32:551-67.

   Many health status surveys have been designed for mail, telephone, or in-person administration. However, with rare exception, investigators have not studied the effect the survey mode of administration has on the way respondents assess their health and other important parameters (such as response rates, nonresponse bias, and data quality), which can affect the generalizability of results. Using a national sampling frame of noninstitutionalized adults from the General Social Survey, we randomly assigned adults to a mail survey (80%) or a computer-assisted telephone survey (20%). The surveys were designed to provide national norms for the SF-36 Health Survey. Total data collection costs per case for the telephone survey ($47.86) were 77% higher than that for the mail survey ($27.07). A significantly higher response rate was achieved among respondents randomly assigned to the mail (79.2%) than telephone survey (68.9%). Nonresponse bias was evident in both modes but, with the exception of age, was not differential between modes. The rate of missing responses was higher for mail than telephone respondents (1.59 vs. 0.49 missing items). Health ratings based on the SF-36 scales were less favorable, and reports of chronic conditions were more frequent, for mail than telephone respondents. Results are discussed in light of the trade-offs involved in choosing a survey methodology for health status assessment applications. Norms for mail and telephone versions of the SF-36 survey are provided for use in interpreting individual and group scores.

10. Lyons RA, Perry HM, Littlepage BN. Evidence for the validity of the Short-form 36 Questionnaire (SF-36) in an elderly population. Age & Ageing 1994; 23:182-4.

    The objective of this study was to determine whether the Short-form 36 Health Status Questionnaire (SF-36) is suitable for use in an elderly population. The SF-36 was administered by interview to a random sample of 827 adults from West Glamorgan. Among the 216 adults aged 65 and over the data were 98.8% complete. Evidence for a high degree of internal consistency was good with Cronbach's alpha statistic exceeding 0.8 for each parameter. The evidence for construct validity was also good with the SF-36 distinguishing between those with and without markers of poorer health. The SF-36 is suitable for use with an elderly population when used in an interview setting.

11. Bell DS, Kahn CE Jr. Assessing health status via the World Wide Web. In: Cimino JC, ed. Proceedings of the AMIA Annual Fall Symposium. Philadelphia: Hanley & Belfus, 1996: 338-342. [PostScript]

    We explored the use of the World Wide Web to collect health status information for medical outcomes research. The RAND 36-Item Health Survey 1.0 (RAND-36), which contains the 36 multiple-choice questions of the Medical Outcomes Study SF-36 "Short Form" and differs only in its simplified scoring scheme, was made available for anonymous use on the Internet. Participation in the survey was invited through health-related Internet news groups and mailing lists. Participants entered data and received their scores using the World Wide Web protocol. Entries were recorded from 15 June 1995 to 14 June 1996 (1 year). The survey was completed anonymously by 4876 individuals with access to the World Wide Web. Two-thirds completed the survey within 5 minutes, and 97% did so within 10 minutes. The item-completion rate was 99.28%. Values of Cronbach's alpha of 0.76 to 0.90 for the scoring scales matched the high reliability found in the Medical Outcomes Study. The World Wide Web provides a method of rapidly measuring individual health statuss and may play an important role in advancing health services research and outcomes-based patient care.