Journal of Public Health Medicine
46-50
Measuring health status with the SF-36:
the need for regional norms
Ronan A. Lyons, Hilary Fielder and Beverley N. C. Littlepage
Abstract
Background. Normative data on SF-36 scores in popu-
lations from Oxford and Aberdeen have recently been
published. It has been suggested that such data provide
suitable normative values for the UK population. However,
other indices of health vary considerably across regions,
and tend to be worse in areas such as South Wales. The
objective of this study was to determine whether population
SF-36 scores in West Glamorgan differ from scores from
other parts of the United Kingdom.
Method. The SF-36 health status questionnaire was
administered to two random samples of adults aged 2 0 -
89 years, drawn from the West Glamorgan Family Health
Services Authority register. One sample (/7 = 919) received
postal questionnaires and those in the other sample
(/7 = 1201) were interviewed in their own homes. Norma-
tive data from this study were compared with published
data from other areas of the United Kingdom.
Results: SF-36 population scores were significantly lower
in the two West Glamorgan samples; this was not due to
differences in age, sex, social class, or response rates.
Conclusion: Health status in West Glamorgan, as measured
by the SF-36, is lower than in Oxford or Aberdeen. A
national study would be required to provide appropriate
normative data for the UK population.
Introduction
Until recently, there were not many pragmatic
measures of health-related quality of life developed
for use in the general community. One such measure,
however, is the short form 36-item health survey (SF-
36), which was developed for use in the Rand
Corporation's Health Insurance Experiment in the
United States.1'2 An anglicized version of the SF-36 has
been validated for use in the United Kingdom, and two
studies providing normative data for populations in
Oxford and Aberdeen have recently been published.3'4
A further study collected data on the populations
attending two particular practices in the Sheffield area.5
Practice-based studies may suffer from a variety of
selection biases and such data cannot be considered to
be normative for a geographical area.
In West Glamorgan, the Health Authorities decided
to use the SF-36 to provide baseline data on the health
Vol. 17, No. 1, pp.
Printed in Great Britain
of the population in 1993 and to repeat this exercise in
1998. As other health indicators differ across regions, it
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was decided to compare the results in West Glamorgan,
Oxford and Aberdeen, and to consider whether there is
a need for regional normative data for the SF-36.
Method
The SF-36 is a 36-item questionnaire which measures
eight parameters of health status: physical functioning,
social functioning, role limitations owing to physical
problems, role limitations owing to emotional
problems, mental health, pain, vitality and general
health perception. For each item, scores are coded,
summed and transformed to a scale from 0 to 100,
where a higher score indicates better health status.
A booklet questionnaire of the SF-36 was adminis-
tered to two samples of adults (aged 20-89 years)
randomly drawn from those registered with the Family
Health Services Authority. Those in the first sample
selected (n = 1201) were visited in their homes by
health visitors, and those in the second sample (n =
919) received the questionnaire by post with two
follow-up reminders, each two weeks apart.
As the Oxford and Aberdeen studies used postal
surveys, the West Glamorgan postal results were
compared with the published results of these two
studies.3'4 The Oxford study randomly selected their
sample from Family Health Services Authorities
registers and the Aberdeen group selected a random
sample from the electoral register. The two West
Glamorgan samples were also compared with one
West Glamorgan Health Authorities, 36 Orchard Street, Swansea SA1
5AQ.
RONAN A. LYONS, Consultant in Public Health Medicine
HILARY FIELDER. Registrar in Public Health Medicine
BEVERLEY N. C. LITTLEPAGE, Director of Public Health
Medicine
Address correspondence to Dr R. A. Lyons.
© Oxford University Press 1995
 H E A L T H STATUS M E A S U R E M E N T 47

TABLE 1 Comparison between Aberdeen and West Glamorgan scores on the SF-36

Aberdeen (postal) West Glamorgan (postal)

Age group 16-91 Age group 20-89 Difference

Physical function 79-2 723 -5-9

Social function 786 75-8 -2-8
Role function - physical 76-5 67-1 -9-4
Role function - emotional 750 71-6 -3-4
Mental health 73-7 71-5 -2-2
Vitality 61-2 570 -4-1
Bodily pain 769 69-2 -7-7
General health perception 68-7 641 -4-6

TABLE 2 Differences between West Glamorgan and Oxford scores on the eight variables of the SF-36. The x 2 test

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means in men and women aged 55-64 years was used to assess differences in proportions between
the interviewed and postal samples. The Mest was also
Parameter Men Women used to compare differences in results between specific
age, sex, and social class groups from the West
Physical function -9-5 -18-5
Glamorgan, Oxford and Aberdeen studies.3'4
Social function -74 -19 7
Role function - physical -20-8 -27-8
Role function - emotional -80 -10-3 Results
Mental health -0-2 -11
Vitality + 0-1 -13-5 From the 1201 individuals selected for interview, 825
Bodily pain -15-8 -29-5 (69 per cent) completed questionnaires were obtained.
General health perceptions -3-2 -119 However, the health visitors discovered that 192
persons or 16 per cent of the sample selected had
either moved or died. When these are excluded from the
another, to determine whether the different sampling analysis, the response rate becomes 82 per cent. In the
methods produced similar results. postal branch of the survey, 532 (57-9 per cent)
The Mann-Whitney test was used to determine completed questionnaires were returned, which, when
whether the interviewed and postal groups differed in allowances were made for the 16 per cent of the sample

TABLE 3 Mean (SD) scores and sample sizes for eight dimensions of SF-36 in
the interviewed and postal samples

Variable Interviewed Postal p value

Physical functioning 76-2 (30-3) 72 3(31-6)

n = 827 n = 529 0009
Social functioning 80-6 (28 7) 75-8 (29-6)
n = 824 /7 = 523 0001
Role limitations - physical 72-5 (28-7) 67 1 (29-6)
/7 = 826 n = 519 0 013
Role limitations - emotional 82-8 (350) 71-6(41-0)
n = 824 n = 519 0001
Mental health 75-3 (19-5) 71-5 (201)
n = 822 n = 517 0001
Vitality 58 4 (24-1) 570 (23-8)
n = 821 n = 518 0265
Pain 70-9 (300) 69-2 (29-7)
n = 822 /7 = 522 0-230
General health perceptions 66-6 (260) 64-1 (26-2)
n = 927 A) = 532 0056
48 JOURNAL OF PUBLIC HEALTH MEDICINE

TABLE 4 Mean (SD) scores and sample sizes for eight dimensions of SF-36 for men by age (postal sample)

Age (years)

Variable 20-29 30-39 40-49 50-59 60-69 70-79 80-89

Physical functioning 94-2(13-6) 92-6(13-6) 85-1(26-4) 75-8(28-2) 61-1(30-7) 56-0(27-8) 50 3 ( 3 1 0 )

n ™ 31 n = 46 n — 30 n — 3/ n = 39 n ~ 28 /? = 6
Social functioning 85 8 ( 2 3 4) 82-3(22-6) 82-5(25-1) 80-7(26-6) 75-3(27-2) 75-9(26-2) 70-8(42-4)
n = 30 n — 46 ^ = 30 n — 37 n = 37 /7 = 28 /7 = 6
Role limitations - physical 89 5 (24 8) 84-8 (32-7) 80-8 (37-5) 70-9 (42-7) 53-5 (46-3) 5 0 0 (44-4) 2 0 0 (44-7)
/7 = 31 n = 46 /7 = 30 /? = 37 n = 36 n = 27 /i = 5
Role limitations - emotional 82 8(35-3) 81-9(34-2) 80-0(33-4) 80-6(36-0) 66-7(42-9) 70-4(43-7) 22-2(40-4)
,, = 31 n = 46 n = 30 n = 36 n = 36 n = 27 /) = 5
Mental health 74-1(23-2) 790(14-6) 74-7(18-6) 75-8(20-5) 75-0(14-6) 75-5(21-5) 52-8(29 6)
n = 30 n = 46 n = 30 n = 37 /7 = 38 /? = 26 /7 = 5
Vitality 64-8(15-3) 68-4(20-5) 64-9(21-4) 62-3(24-8) 57-6(25-8) 60-2(18-2) 470(295)

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n = 30 /7 = 46 n = 30 n = 37 n = 37 n = 26 n = 5
Pain 87 5 ( 1 6 2) 82-6(22-9) 71-8(27-6) 68-6(32-1) 60-9(29-1) 63-1(30-1) 62-7(15-2)

General health perceptions 78-3(16-8) 77-8(22-5) 70-9(23-7) 65-6(25-9) 52-9(26 4) 55-3(32-8) 590(21-2)
/? = 31 n = 46 n = 30 n = 37 /? = 39 n = 28 /7 = 6

who were likely to have moved or died as in the
interviewed branch, yielded a corrected response rate of
69 per cent. The age and sex distribution of the postal
and interviewed samples were similar and comparable
with the population distribution in the 1991 Census. 6
The Aberdeen study published normative data for
the entire postal sample, whose age ranged from 16 to
91 years. 4 Table 1 compares the population mean from
the West Glamorgan postal sample (age range 20-89
years) with the Aberdeen means. Scores from the West
Glamorgan sample were on average 5 0 points lower
[95 per cent confidence interval (CI) -2-92 to -7-10].
In the Oxford study means were given by decennial
age groups and sex. Sixty-four possible age and sex
groups were compared (age groups 25-34, 35-44, 4 5 -
54, 55-64 years; both sexes, eight parameters of the SF-

TABLE 5 Mean <SL>) scores and sample sizes for eight dimensions of SF-36 for women by age (postal sample)

Age (years)

Variable 20-29 30-39 40-49 50-59 60-69 70-79 80-89

Physical functioning 88 3(21-9) 89-1(20-1) 80-7(25-4) 64-1(32-4) 62-6(30-9) 43-8(31-6) 284(29-9)

n = 40 n = 46 /7 = 58 /? = 40 A? = 5 4 n = 42 /? = 17
Social functioning 81-9(26-7) 81-8(24-4) 72-6(29-8) 73-4(33-2) 6 9 1 ( 3 5 5) 67-7(31-5) 516(438)
n = 40 n = 46 n ^ 58 n ^ 40 A7 ^ 53 n == 41 /? = 16
Role limitations - physical 87-2(280) 90-6(25-2) 70 3 ( 4 0 1 ) 59-8(46-7) 51-4(460) 42-7(450) 200(31-6)
/# O? ' * ^ ^ "TV // V& It ^^ " I »/ O^ ' * ^^ " I #/ ^ ^ I *J

Role limitations - emotional 77-8(35-3) 79-7(34 8) 71-2(40-3) 73-6(420) 61-9(46-2) 56-9(48-4) 51-1(48-6)
/? = 39 /? = 46 /7 = 59 o = 41 n = 52 /7 = 40 n = 15
Mental health 68-4(21-1) 72-6(180) 66-4(22-7) 64-7(20-1) 71-1(19-1) 72-8(190) 639(28-3)
r) = 40 ri == 46 n ^ 56 n ^ 40 A7 ^ 53 rt ^ 40 ^7 = 1 5
Vitality 55-2(24-0) 65-8(20-5) 51-4(23-7) 48-8(240) 54-2(23-8) 512(24-6) 30-3(24-6)

Pain 80 2 ( 2 5 8) 80-8(25-4) 75-5(23-4) 57 8(32-3) 60-5(30-5) 53 0(30-1) 43-3(33 6)

General health perceptions 703(21-8) 79-3(18-3) 66-2(21-6) 60-6(28-4) 58-6(29-3) 49-8(24-8) 3 1 0 ( 2 8 3)

o = 41 n = 46 n = 59 n = 41 n = 54 /7 = 42 n = 17
 HEALTH STATUS MEASUREMENT
36). Average scores in West Glamorgan were 6-61
points lower (95 per cent CI -4-81 to —8-41). In the
younger age groups, differences in scores tended to be
smaller, whereas scores diverged in the older groups.
Table 2 shows the mean scores in men and women aged
55-64 in the West Glamorgan and Oxford samples.
When the postal and interviewed samples from West
Glamorgan were compared, the postal means were
significantly lower than the interviewed means in five of
the eight variables measured by the SF-36 (Table 3).
Normative data for West Glamorgan men and women
are shown in Tables 4 and 5. The data in the tables are
from the postal samples. Normative data from the
interviewed samples are available from the authors on
request.
Discussion
The SF-36 is a useful tool for measuring patients'
perceived health status. 1 ' 2 Scores from this question-
naire will undoubtedly be used to judge clinical
outcomes and the effectiveness of various interven-
tions. There are, however, several problems which
might occur when comparisons are being made across
the country.
It is likely that many of the studies of patient groups
and therapies using the SF-36 currently under way will
compare changes in health status with normative
values. However, it is a central tenet of epidemiology
that like should be compared with like. This study has
shown that population norms for the SF-36 do in fact
differ between areas of Wales, Scotland and England.
Such differences would, of course, be expected, as the
health status of people living in these areas is known to
differ.
The 1991 Census reported that the prevalence of
long-term limiting illness varied considerably across the
country, with rates of 129/1000 in Scotland (Aberdeen),
110/1000 in the South East of England (Oxford), and
164/1000 in Wales (West Glamorgan). 7 In Oxford and
Aberdeen, and this study (data not shown), persons
with longstanding limiting illnesses scored lower on the
SF-36 parameters, which is also consistent with the
overall lower scores in West Glamorgan. 3 ' 4
There are two other possible explanations for the
lower SF-36 scores in the West Glamorgan population.
As SF-36 scores also vary by social class, differences in
scores between areas might reflect differences in social
class distribution across the country. It was possible to
assign a social class, using the Registrar General's
standard occupational classification, to 88 per cent of
respondents in the Oxford study and 83 per cent in the
West Glamorgan study.8 In the West Glamorgan
sample a higher proportion of respondents were
49
assigned to social classes 4 and 5 (21-2 per cent versus
15-3 per cent) whereas the proportions from social
classes 1 and 2 were similar in the two areas (36-1 per
cent and 36-8 percent). However, the higher proportion
of persons from social classes 4 and 5 is not the
complete explanation for the difference in mean scores
between the two areas; when scores were compared
between Oxford and West Glamorgan by social class
groupings for each of the eight variables of the SF-36,
the West Glamorgan scores remained lower on average
(mean difference -2-84, 95 per cent CI —1-26 to
-4-42).
The other possible explanation for the lower scores in
West Glamorgan may be related to a response rate bias.
In the Oxford study the response rate was 72 per cent,
compared with 58 per cent in the West Glamorgan
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postal sample. If healthier people were more likely to
return questionnaires this could explain the higher
population means in the Oxford sample. In this study,
interviewed respondents did report significantly better
health on five of the eight health parameters in the
interviewed sample, which had a response rate of 69 per
cent. However, response rate bias does not explain the
difference between the Oxford and West Glamorgan
results; when the West Glamorgan interviewed means
were compared with the Oxford means by age group,
sex and SF-36 parameters, the West Glamorgan scores
were lower on average by 3-27 points (95 per cent CI -
1-90 to -4-64).
The differences between the postal and interviewed
West Glamorgan samples is interesting and potentially
important. It may be that the differences are due to a
response rate bias or it may be that people respond
differently to the SF-36 when it is self completed or
interview administered. A randomized cross-over study
design would be required to answer this question. It is
important that this question be answered, as it has
implications for which norms are appropriate when
comparisons are being made between data collected
from interviewed patients and population norms.
The main message of this paper, however, is that
studies using the SF-36 show regional differences in
population health status and that these differences are
in the directions expected. Thus, regional normative
data on the SF-36 are required for studies whose
outcome is measured by the degree of return to
'normal' function in patient groups from different
parts of the country.
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