1. Cross-Cultural Use of Measurements: Development of the Chinese SF-36 Health Survey Xinhua S. Ren, Ph.D. Boston University School of Public Health, Boston, MA Center for Health Quality, Outcomes, and Economic Research, Bedford Veterans Hospital, Bedford, MA Funded by the Agency for Health Care and Policy Research

2. Outline Background Need for non-English survey instruments Strategies Development of the Chinese SF-36 Health Survey Psychometric testing Application among elderly Chinese Americans

3. Introduction Health-related quality of life (HRQoL) measures are rapidly becoming standard tools –assess health status –monitor patient health status –evaluate the quality, efficiency, and effectiveness of patient care

4. Introduction (cont.) HRQoL measures are reliable and valid Easy to collect and for less cost

5. Demographic Transition and Cross- Cultural Use of Health Status Measures Ethnic diversity is transforming America into a multicultural society –By 2000, 25% minority populations –By 2050, > 50% minority populations An increased interest in providing culturally appropriate health care services

6. Demographic Transition and Cross-Cultural Use of Health Status Measures (cont.) Most HRQoL instruments have been developed in English The absence of information makes it difficult to plan and implement culturally responsive health care programs

7. Developing a Culturally-Appropriate Health Status Measure To construct a new HRQoL measure –advantage: cultural specific To translate and adapt HRQoL measures previously developed and validated in English –advantage: appropriate for cross-cultural comparison Two different strategies:

8. Translation and Adaptation of HRQoL Measures Selection of health related quality of life measures Use of systematic approaches

9. Selection of Health Status Measures Reliability –produces consistent results Validity –measures what it is supposed to measure Easy administration –the amount of time required to complete the instrument) Three criteria:

10. Why SF-36? Three considerations: SF-36 contains fewer questions to be administered SF-36 has been proven to be psychometrically sound SF-36 is based on a multidimensional model of health

11. MOS SF-36 –physical functioning (PF) –role limitations due to physical health (RP) –bodily pain (BP) –general health perceptions (GH) SF-36 measures 8 different domains of health

12. MOS SF-36 (cont.) SF-36 measures 8 different domains of health (cont.) –vitality (VT) –social functioning (SF) –role limitations due to emotional problems (RE) –mental health (MH)

13. MOS SF-36 (cont.) The 8 scales are scored from 0 (worst health) to 100 (best health) The 8 scales can be combined into 2 summary scales –physical (PCS) & mental (MCS) –scored using a linear t score transformation, normed to a general US population with a mean of 50 and a standard deviation of 10

14. Approach of Translation and Adaptation Two general principles –replicate the original as closely as possible –be sensitive to cultural adaptations Systematic protocols –Three forward translations –Committee review –Two back-ward translations –Committee review

15. Adaptation of MOS SF-36 Adaptations on items that make little sense in Chinese –“full of pep” “liveliness” or “vigor” –“down in the dumps” “low in mood” –“downhearted and blue” “sadness” –“a mile” “a kilometer” –“several blocks” “several hundred meters” –“playing golf” “practicing Tai Chi”

16. Testing the Reliability and Validity of the Translation Item-internal consistency –the correlation between an item and its hypothesized scale > 0.40 Internal consistency reliability (Cronbach’s alpha) –real variation as opposed to random error Test-retest reliability –consistent scores on two or more administrations

17. Equivalent-Forms Reliability –agreement between the scores –consistent ordering of item mean scores Testing the Reliability and Validity of the Translation (cont.) Construct validity (known-groups validity) – discriminating among various groups

18. Data –A convenience sample of 156 respondents in Boston, Massachusetts (Sample 1) –A convenience sample of 321 subjects from Tucson, Arizona (Sample 2) – A convenience sample of 219 elderly Chinese in Boston, Massachusetts (Sample 3) Three data sources

19. Item-Internal Consistency (Sample 1) Vitality PF RP BP GH VT SF RE MH VT1.27.44.33.38.55*.40..37.41 VT2.31.52.41.50.64*.46.46.51 VT3.26.35.28.41.51*.48.46.58+ VT4.20.34.22.41+.39*.34.47+.52+ Social Function SF1.22.35.40+.34.37.39*.43+.39+ SF2.35.46.37.48+.54+.39*.33.50+

20. Internal Consistency Reliability (Cronbach’s alpha) (Sample 1) SF-36 scalesCronbach’s alpha PF.92 RP.82 BP.78 GH.82 VT.73 SF.54 RE.88 MH.74

21. One-Week Test-Retest Reliability (Sample 2) Product-moment correlations SF-36Chinese-ChineseEnglish-English (n = 77) (n = 78) PF0.900.81 RP0.690.70 BP0.680.83 GH0.740.78 VT0.830.79 SF0.670.80 RE0.780.84 MH0.860.87

22. Equivalent-forms Reliability (Sample 2) SF-36English-ChineseChinese-Englishz-score (n = 75)(n = 79) PF0.980.82 6.93 RP0.810.92-2.80 BP0.920.95-1.47 GH0.880.88 0.00 VT0.970.88 4.35 SF0.900.87 0.84 RE0.940.99-5.52 MH0.950.92 1.47

23. Construct Validity: Quality of the Translation Item means SF-36 PFChineseU.S. Vigorous activities1.872.17 Climb several flights2.502.54 Bend, kneel2.592.59 Walk mile2.572.55 Moderate Activities2.442.65 Lift, carry groceries2.672.72 Walk several blocks2.672.69 Climb one flight2.832.78 Walk one block2.862.82 Bathe, dress2.892.88

24. Construct Validity: SF-36 health profile for various Chinese groups and U.S. norm

25. Applying the Chinese SF-36 among Elderly Chinese Limited Health Status Data –The myth of a healthy minority model –Inappropriateness of using mortality to assess health status –A high risk and high need population

26. Characteristics (N=219) Percent / Mean Age (range: 55-96) 69 (s.d.=7.6) Female 61% Married 68% < Middle school 59% Income < $9,999 59% $10,000-29,999 31% $30,000 10% Length of stay, y 13 (s.d.=10.7) Number of medical symptoms 1.6 (s.d.=1.4)

27. SF-36 Health Profiles for Elderly Chinese and U.S. Norm SF-36Chinese elderlyU.S. norm U.S. norm scales(mean age = 69)(ages 65-74) (ages  75) (n = 219)(n = 442) (n = 264) PCS43.3 (9.0)43.5 (11.2) 38.0 (11.2)* MCS47.1 (10.9)52.6 (9.3)* 50.8 (11.7)* * P < 0.001 level.

28. Conclusions –selection of currently available instrument over the development of new instruments –need to conduct psychometric tests To develop valid and reliable cross-cultural measures

29. Conclusions (cont.): The translation and adaptation of the SF-36 into Chinese is successful –it satisfies conventional psychometric criteria –It discriminates well healthy populations from sick patients –It is valuable in general population surveys as well as clinical practice or research –assisting doctors understand better about the feelings of their Chinese patients –improving quality of patient care