-

Patient-Reported Outcomes
Contents lists available at sciencedirect.com
Journal homepage: www.elsevier.com/locate/vhri

Translation, Cultural Adaptation, and Validation of Short-Form 6D on the

General Population in Indonesia
Tri M. Andayani, PhD,1,* Susi A. Kristina, PhD,2 Dwi Endarti, PhD,2 Restu N.H. Haris, MSc,3 Anindya Rahmawati, MClin Pharm4
1
Department of Pharmacology and Clinical Pharmacy, Universitas Gadjah Mada, Yogyakarta, Indonesia; 2Department of Pharmaceutics, Universitas Gadjah Mada,
Yogyakarta, Indonesia; 3Master Program in Pharmaceutical Science, Universitas Gadjah Mada, Yogyakarta, Indonesia; 4Master Program in Clinical Pharmacy,
Universitas Gadjah Mada, Yogyakarta, Indonesia

A B S T R A C T

Objectives: This study aims to translate, culturally adapt, and validate the Short-Form 6D (SF-6D) instruments for measuring
quality of life as outcome parameters in pharmacoeconomic studies.
Methods: The forward-backward methods were applied to translate the SF-6D questionnaire. A preliminary Indonesian
version of SF-6D questionnaire was field tested in samples of 470 adult general population. Test–retest reliability was
assessed by using Spearman rank correlation coefficient and internal consistency with Cronbach a. Face validity was
assessed descriptively based on the response of the respondents to all items in SF-6D. The construct validity test included
internal construct validity and convergent validity, which was assessed by examining the correlation between the
questionnaire and Euro-Quality of life-5D based on the scale of each domain. The known group method was used to test
discriminant validity. Mann-Whitney U test was employed for comparing the utility score on dichotomous variables and
Kruskal-Wallis H test was used for polychromatic variables.
Results: The SF-6D was a valid and reliable questionnaire, indicated by the reliability coefficient of 0.725 and the value of each
item ranging from 0.698 to 0.750. Construct validity indicated a strong correlation between physical functioning, role
limitation, social functioning, pain, and mental health with the SF-6D utility score. Convergent validity showed a weak
and moderate correlation between dimensions on SF-6D and Euro-Quality of life-5D.
Conclusions: The SF-6D questionnaire has been translated into Indonesian version. The SF-6D questionnaire is valid and
reliable. Known group validity shows that the SF-6D could differentiate utility scores by age group and history present illness.

Keywords: cultural adaptation, general population, Short-Form 6D, translation, validation.

VALUE IN HEALTH REGIONAL ISSUES. 2020; 21(C):205–210

Introduction There are several instruments to measure utilities, including

The rapid development of health technology, limited economic
resources, and application of technology with an economic
dimension (the more sophisticated the technology, the more
expensive the costs required), require a priority on health tech-
nology used for services to select which should be restricted and
which should be abandoned.1
The most recommended method for assessing health tech-
nology is cost-utility analysis. The output of cost-utility analysis is
stated with utilities related to changes in life expectancy and
quality of life owing to health interventions. The utility unit is then
calculated into the quality-adjusted life years after considering the
additional years of the patient's life.1–3
Euro-Quality of life-5D (EQ-5D), Health Utility Index (HUI),
Quality of Well Being, and Short Form-6D (SF-6D).4 EQ-5D is the
most frequently used instrument and consists of 2 parts. The
first part describes 5 dimensions of problems, each consisting of
3 and 5 levels, and the second is the visual analog scale (VAS)
in the vertical form, where the lowest value is 0, which de-
scribes the worst health status, and 100 in the highest value,
which describes the best health status. By using time trade-off
(TTO) technique, the United Kingdom, Norway, and Japan have
developed algorithms for EQ-5D scoring.2,5–7 Nowadays, 32
value sets for EQ-5D-3L and 14 value sets for EQ-5D-5L have
been made in several countries using TTO and visual analog
scale techniques.8

Conflict of interest: The authors have indicated that they have no conflicts of interest with regard to the content of this article.
* Address correspondence to: Tri M. Andayani, PhD, Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy Universitas Gadjah Mada, Jl.
Persatuan (Sekip Utara) Yogyakarta, Indonesia 5528. Email: trimurtia@ugm.ac.id
2212-1099/$36.00 - see front matter ª 2020 ISPOR–The professional society for health economics and outcomes research. Published by Elsevier Inc.
https://doi.org/10.1016/j.vhri.2019.11.004
206 VALUE IN HEALTH REGIONAL ISSUES
SF-6D, an instrument developed from SF-36, is increasingly
being used to measure health in general in clinical study. Chen
et al5 reported that SF-6D was more efficient in detecting differ-
ences in health status in patients with chronic obstructive pul-
monary disease. In line with Chen et al,5 Thaweethamcharoen
et al9 also reported that in patients with peritoneal dialysis, SF-6D
showed a better correlation with kidney disease–specific di-
mensions. Research from van Stel et al10 shows that the means of
coronary heart disease patient’s utility assessed with the EQ-5D
and SF-6D are the same, but the median, score range, and sensi-
tivity to changes after intervention are different. The EQ-5D and
SF-6D show different values in congestive heart failure patients
based on the severity of the disease (ie, in the domain of func-
tional capacity). The EQ-5D shows higher score than SF-6D in the
less severe group of patients and a lower score in the more severe
group.11 In more severe rheumatoid arthritis patients, the median
score of the EQ-5D is lower than the median score of the SF-6D.12
The SF-6D consists of 6 dimensions (physical functioning, role
limitation, social functioning, pain, mental health, and vitality)
consist of 4 to 6 levels, respectively. The SF-6D was developed
from the response of 11 SF-36 domains, which were combined
into 6 health dimensions with 4 to 6 levels for each domain. The
SF-6D descriptive system was obtained from 18 000 possible
health states, of which 249 values were assessed directly from 611
UK population samples using the standard gamble (SG) method.13
The difference in methodology for obtaining a utility score can
have implications for utility values.10 The EQ-5D health state was
assessed using the TTO method, whereas the health state of the
SF-6D was assessed using SG. It is well known that SG generally
produces higher values than TTO, especially in more severe con-
ditions. The EQ-5D is less sensitive than the SF-6D in assessing
patients' health conditions that are less severe, whereas the EQ-5D
is better than the SF-6D for detecting more severe patient health
status.5,11 Research in populations with different health states
shows different mean values of the EQ-5D and SF-6D, which
means the 2 instruments are not interchangeable.13 Variations in
the estimation of utility scales and quality-adjusted life years will
influence decision making on the resources used.5
In Indonesia, it is recommended that utility measurements are
carried out using the EQ-5D instrument because it is easy to un-
derstand, can be used to measure perceptions of quality of life in
patients with different diseases, and its value set is available for
the Indonesian population.14 The algorithm for SF-6D scoring has
been developed by the University of Sheffield, United Kingdom.
However, the choice of suitable instruments must be based on the
measurement needs of certain intervention. Therefore, with the
Indonesian version of the SF-6D questionnaire, an alternative in-
strument is available to measure the utility of patients based on
the interventions studied. Recently, the SF-6D is not yet available
in Bahasa Indonesia; therefore, there is a need of translation,
cultural adaptation, and validation of the SF-6D instrument as one
of the instruments to measure utility.
Methods
Original questionnaire
The SF-6D is the result of reclassification of 8 dimensions of the
SF-36 instrument into 6 dimensions (ie, physical functioning, role
limitation, social functioning, pain, mental health, and vitality), in
which each domain has questions with 4 to 6 levels of answers.15
The physical functioning domain consists of 6 levels to determine
whether your health was limited, a little limited, or very limited to
activities, whether vigorous or moderate. The role limitation
domain consists of 4 levels, including any problem in performing
- 2020
work or day-to-day activities due to physical health and emotional
issues. The social function domain consists of 5 levels (ie, whether
health limits social activities). The pain domain consists of 6 levels
(ie, whether there is any pain, a little bit of pain, moderate pain, or
extreme pain, which does not disturb work at home or outside of
home). Meanwhile, the mental health and vitality domains consist
of 5 levels of questions related to whether there has been any
tension, desperation, or downheartedness and a lot of energy.16
SF-6D scoring uses an algorithm for utility scoring in the form
of an Excel (Microsoft Corp, Redmond, WA) program developed by
University of Sheffield in which a utility score is estimated using a
set of parametric preference weights obtained from general pop-
ulation using the standard gamble calculation technique. The SF-
6D can describe 18 000 medical conditions. The utility score
scale starts from 0 (describing the worst medical condition) to 1
(describing the best medical condition).2,5,17,18
Translation, cultural adaptation, and validation of the
SF-6D into Bahasa Indonesia
The translation of SF-6D into Bahasa Indonesia was conducted
by using the forward-backward method in the Language Learning
Center of Faculty of Cultural Sciences of Gadjah Mada University
by 2 independent linguists with an area of expertise in language,
communication, and cultural or linguistic structure, and the
retranslation was conducted by a professional translator into En-
glish. Then, the review was conducted by the committee con-
sisting of internists, linguists, methodologists, and pharmacists to
compare between the original and translated questionnaire. A
review was held to ensure the equivalence between the original
questionnaire and SF-6D in Bahasa Indonesia, namely semantic,
idiomatic, and concept equivalence. In addition, it was also to
equalize the perceptions on the existing differences, ensuring that
the questionnaire has clear, acceptable, and understandable in-
structions for the respondents.16,19–22
Psychometric evaluation of the SF-6D in Bahasa
Indonesia
Research design and participants
A cross-sectional design study was conducted from August to
September 2018 in Yogyakarta, Indonesia. The study was con-
ducted in urban and suburban areas of Yogyakarta in a general
population of 500 people with some inclusion criteria, such as age
older than 18 years, willing to participate in research, and have an
ability to fill out the questionnaires provided. If their respondents
were willing to participate, they would be given some explana-
tions related to research and informed consent. Each respondent
was given SF-6D and EQ-5D-5L questionnaires and a question-
naire containing questions related to respondent's demographics,
namely age, sex, education level, occupation, income, and marital
status. The calculation of the EQ-5D utility score uses the value set
developed for the Indonesian population,14 whereas the SF-6D
utility score is assessed by entering each respondent's utility
health score into the Excel program developed by the University of
Sheffield.23,24 The reliability test–retest was performed on 30 re-
spondents by giving the SF-6D questionnaire back after 14 days
without being given intervention. This study has been approved
by the Ethics Committee of Faculty of Medicine of Gadjah Mada
University with number KE/FK/0930/EC/2018.
Statistical analysis
Validity and reliability tests were performed on the Indonesian
language version of SF-6D. Face validity test was performed on 30
participants, in which the respondents were requested to com-
plete the questionnaire consistent with their medical conditions
 PATIENT-REPORTED OUTCOMES 207

Table 1. Sociodemographic and characteristics of general Whitney U test was used for comparing the utility score on
population (n = 470). dichotomous variables and Kruskal-Wallis H test for poly-
chromatic variables. Known group validity is assessed using
Kruskal-Wallis H test to determine the difference between the
Sociodemographic n %
score of each dimension in the SF-6D by age (,45 years, 45-59
Age (y) years, $60 years), education level (primary and below primary
Mean 6 SD 43 6 16
and below, middle school, high school, bachelor and above),
,45 247 52.6
working status (working, retired, other), income level (1 billion
45-59 136 28.9
$60 87 18.5 IDR, 1-3 billion IDR, $3 billion IDR), and marital status (single,
married, divorced/widowed). Meanwhile, sex and history of pre-
Sex
sent illness were assessed using Mann-Whitney test. The reli-
Female 330 70.2
Male 140 29.8
ability for each scale was based on internal consistency value,
namely the correlation between question items. The reliability of
Education
the questionnaire was seen from the coefficient of Cronbach a,
Primary and below 87 18.5
where the value .0.7 showed that the questionnaire is reliable.
Middle school 98 20.9
High school 214 45.5 The correlation between items is accepted if the value is .0.4. The
Bachelor and above 71 15.1 reliability test was also assessed based on the test–retest using the
Spearman correlation coefficient.2,5,19,20,28
Working status
Working 194 41.3
Retired 226 48.1 Results
Others 50 10.6
Monthly household income Translation of SF-6D questionnaire
1 000 000 IDR 223 47.4
1 000 000-3 000 000 IDR 195 41.5 The translation of the original version of the SF-6D question-
$3 000 000 IDR 52 11.1 naire was conducted using the forward-backward method. To
Marriage status prevent bias, the translator did not know the original version of
Single 76 16.2 the questionnaire. The results of the expert review conducted by
Married 343 73 the committee review, consisting of methodologists, internists,
Divorced/widowed 51 10.9 pharmacists, and translators (forward and backward), was con-
ducted by comparing the results of translation with the original
questionnaire and was verified in terms of semantic (word
and ask several items related with the questionnaire. The ques- meaning), idiomatic (expression), and suitability of the concept
tions included respondents’ understanding on the items, whether between the Bahasa Indonesia and the original versions. The re-
there was any ambiguity or not, respondents’ ability to respond sults of the expert review reached a consensus with several
the items, clarity of the items, duration of interview, item order, questions in the Bahasa Indonesia version of the instrument
correct language style and spelling in the instrument. The validity adjusted according to the original version, including the adjust-
test of the SF-6D questionnaire included content validity and ment of the word “achieve less than what you want to” into “the
construct validity.25–27 Content validity was assessed descriptively target is not achieved.” In the domain of pain, the words “normal
based on face validity. The construct validity test included work” was changed to “daily work (inside and outside house),” so
convergent validity, which was assessed by examining the rela- that the respondents could understand better. In the domain of
tionship between the SF-6D questionnaire and EQ-5D-5L based on vitality, the word “having a lot of energy” is changed to “having
the scale of each domain. According to Wu et al,2 a correlation the spirit of life.”
between each utility score of SF-6D and the domain of EQ-5D-5L
was carried out, namely mobility, self-care, daily activity, pain/
Sociodemographic
discomfort, and anxiety/depression. The correlation was based on From a total of 500 respondent data, there were 30 data
the correlation coefficient value with Spearman rank. The known excluded due to incompleteness. The results of analysis on 470
group method was used to test discriminant validity. Patients respondents showed that 70.2% respondents were female, with a
were grouped according to sociodemographic status. Mann- majority ,45 years (52.6%) of age and average age of 43 years, 45%

Table 2. Differences in the SF-6D dimension scores based on demographic characteristics.

Characteristics PC RL SC P MH V
Sex 0.731 0.192 0.360 0.523 0.001* 0.479
Age 0.000* 0.000* 0.002* 0.000* 0.643 0.062
Education 0.000* 0.037* 0.125 0.009* 0.120 0.008*
Working status 0.035* 0.161 0.477 0.028* 0.718 0.438
Monthly household income 0.344 0.192 0.393 0.929 0.768 0.234
Marriage status 0.000* 0.014 0.588 0.000* 0.156 0.096
History of present illness 0.000* 0.000* 0.001* 0.000* 0.181 0.508
MH indicates mental health; P, pain; PC, physical function; RL, role limitation; SC, social function; V, vitality.
*Significance value.
208 VALUE IN HEALTH REGIONAL ISSUES - 2020

Table 3. Internal construct validity of the SF-6D.

Physical function Role limitation Social function Pain SF- Mental health Vitality SF- Utility SF-
SF-6D SF-6D SF-6D 6D SF-6D 6D 6D
Physical function SF-6D 1.000
Role limitation SF-6D 0.465† 1.000
Social function SF-6D 0.372† 0.413† 1.000
† †
Pain SF-6D 0.387 0.397 0.323† 1.000
† †
Mental health SF-6D 0.197 0.181 0.072 0.112* 1.000
Vitality SF-6D 0.063 0.132† 0.125† 0.112* 0.065 1.000
† † † † †
Utility SF-6D 20.678 20.502 20.511 20.756 20.507 20.187† 1.000
SF-6D indicates Short-Form 6D.
*Correlation is significant at the 0.05 level (2-tailed).
†
Correlation is significant at the 0.01 level (2-tailed).

respondents have high school education, and most of respondents
have an income of ,1 million per month (Table 1).
Validity of the SF-6D
The result of face validity showed that all respondents could
respond to all items in the SF-6D. Of 8 items, ambiguity had the
lowest score (80%). The respondents reported ambiguity in ques-
tions on physical functioning and role limitation, which the re-
spondents claimed were more difficult and required more time to
answer. Mann-Whitney and Kruskal Wallis tests were conducted
to determine differences in the value of health-related quality of
life (HRQoL) based on demographic characteristics. Table 2 shows
that there are significant differences in HRQoL scores on the
physical function and pain dimensions based on age, education
level, employment status, marital status and history of patient
illness. Differences in age and history of patient illness affect all
dimensions in the SF-6D, except in the dimensions of mental
health and vitality.
Internal construct validity was conducted by using Spearman
rank correlation between the dimensions in the SF-6D question-
naire. The internal construct validity of the SF-6D showed a strong
correlation (.0.5) in the domain of physical functioning, role
limitation, social functioning, pain, and mental health with the SF-
6D utility score. The moderate correlation was shown between
physical function, role limitation, social function, and pain (0.35-
0.5), whereas other dimensions showed a weak correlation (0.2-
0.35; Table 3). Convergent validity shows a moderate correlation
between the dimensions of the physical function and the usual
activity dimension and the EQ-5D health utility index. Moderate
correlates relationships are also shown in role limitation SF-6D
dimensions with usual activity, anxiety, and EQ-5D utility index,
the pain SF-6D dimension with pain or discomfort, and the EQ-5D
health utility index. The SF-6D utility index correlates strongly
with the EQ-5D health utility index, whereas the SF-6D health
utility index with the Euro-quality of life-visual analog scale (EQ-
VAS) shows a weak correlation (Table 4).
Reliability
The Spearman rank correlation test was used in the reliability
test–retest by comparing scores from 2 measurements with the
same questionnaire without intervention. The result of the reli-
ability test–retest showed that the SF-6D was reliable and stable
because it had good correlation for every domain (ie, 0.577-0.819;
.0.5). The reliability of each domain was assessed based on in-
ternal consistency using Cronbach a with a value of 0.725 (.0.7)
can be accepted or can be said to be a reliable questionnaire. The
values Cronbach a of items ranged between 0.698 and 0.750. All
items showed a Cronbach a value of more than 0.4 (Table 5).
Discussion
The results show that there are differences in the values of the
EQ-5D-5L, EQ-VAS, and SF-6D, which are 0.944 (SD = 0.093), 82.9
(SD = 8.9), and 0.915 (SD = 0.081), respectively. The EQ-5D-5L

Table 4. Correlations between the SF-6D and EQ-5D or EQ-VAS.

Mobility EQ- Self-care EQ- Usual Pain/ Anxiety/ Utility EQ- VAS EQ-
5D 5D activities discomfort depression 5D 5D
EQ-5D EQ-5D EQ-5D
Physical function SF-6D 0.201† 0.171† 0.405† 0.214† 0.133† 20.385† 20.203†
† † † † † †
Role limitation SF-6D 0.313 0.245 0.389 0.229 0.352 20.350 20.250†
Social function SF-6D 0.131† 0.150† 0.281† 0.199† 0.136† 20.252† 20.077
† † † †
Pain SF-6D 0.236 0.091* 0.179 0.433 0.268 20.427† 20.163†
† †
Mental health SF-6D 0.071 0.001 20.015 0.081 0.180 20.150 20.151†
Vitality SF-6D 0.088 0.038 0.098* 0.028 0.104* 20.630 20.048
† † † † † †
Utility SF-6D 20.247 20.137 20.254 20.392 20.286 0.515 0.218†
EQ-5D indicates Euro-Quality of life-5D; SF-6D, Short-Form 6D.
*Correlation is significant at the 0.05 level (2-tailed).
†
Correlation is significant at the 0.01 level (2-tailed).

Table 5. Spearman rank correlations and Cronbach a coefficients.
Item Test
Spearman coefficient Cronbach a Mean
PC1 0.704 0.698
RL1 0.577 0.715
SF1 0.627 0.709
P1 0.697 0.727
MH1 0.819 0.738
V1 0.817 0.750
MH indicates mental health; P, pain; PC, physical function; RL, role limitation;
SC, social function; V, vitality.
utility index shows a greater value than the SF-6D. This is in line
with the research in the general population in the United States,
which shows the average EQ-5D index score of 0.8739 (SE =
0.0022) higher than the SF-6D index score, which is 0.8126 (SE =
0.0017).6 Nguyen et al reported utility index scores in the general
population in Vietnam of 0.91 (SD = 0.15) using the EQ-5D and
87.4 (SD = 14.3) EQ-VAS.29
The results of psychometric test showed that SF-6D is a valid
and reliable measurement tool for HRQoL in general populations.
In general, the performance of the SF-6D, based on the internal
construct validity, convergent, and known group validity showed
good results. Internal construct validity showed a strong corre-
lation in all domains to the SF-6D utility index, except for vitality
domain. Convergent validity showed a strong correlation between
the SF-6D utility index and the EQ-5D utility index and moderate
and low correlation between domains on the SF-6D and EQ-5D.30
Table 4 shows that the correlation between the mobility dimen-
sion of EQ-5D and physical function SF-6D was lower than the
correlation between the mobility dimension of EQ-5D and pain
SF-6D and role limitation SF-6D. This was because the question
items in both instruments were different, in which the mobility
dimension of EQ-5D is assessed by mobility, whereas the physical
function dimension SF-6D is assessed by limitation in heavy and
moderate activities in addition to bathing and dressing. Similarly,
the correlation between the anxiety dimension of the EQ-5D and
mental health dimension of the SF-6D was lower than the cor-
relation between the anxiety dimension of the EQ-5D and pain
dimension of the SF-6D and role limitation of the SF-6D. Role
limitation dimensions of the SF-6D were assessed by type of work
or other activities because physical health or emotional problem
and pain dimension of the SF-6D were assessed by the pain that
interferes with normal work (both outside the home and house-
work), unlike the questions in the pain dimension of the EQ-5D.
The difference between the question items led to different
scores among the dimensions of the EQ-5D and SF-6D. This was
due to differences in the measured dimensions, where the aspects
measured in the SF-6D were greater with a different measure-
ment scale. In addition, the EQ-5D utility index assessment has
used the Indonesian value set of the population, whereas the SF-
6D utility index estimation used an algorithm from the United
Kingdom. Value sets are different from one country to another,
and there is need to develop value sets for more countries to
consider cultural differences.31 Gundle et al17 performed the SF-
6D validity test on sarcoma patients. The convergent validity
and face validity showed valid results and positive correlation (r =
0.75, P , .01).17 However, Busija et al32 reports that convergent
and discriminant validities of the SF-6D in several studies show
consistent results (ie, moderate correlation with HRQoL scale, and
PATIENT-REPORTED OUTCOMES 209
Item Retest
SD Cronbach a Mean SD
1.53 0.68 PC2 0.722 1.43 0.67
1.36 0.55 RL2 0.742 1.30 0.46
1.30 0.70 SF2 0.681 1.36 0.85
1.83 0.74 P2 0.728 1.83 0.74
2.06 0.69 MH2 0.756 2.16 0.69
1.13 0.43 V2 0.762 1.1 0.40
low but still substantive compared with specific questionnaire).32
Jin et al33 compare the SF-6D with the EQ-5D among 929 rural
residents in China, showing that the convergent validity between
the SF-6D and EQ-5D is strongly correlated (r . 0.574). The results
of relative efficiency and receiver operating characteristic analyses
showed that the SF-6D was more efficient. The aspects measured
in the SF-6D were broader in measuring HRQoL (eg, role and
social functioning with greater level of response for each
domain).33
Known group validity showed that SF-6D could differentiate
utility scores by age group and history present illness. Known
group validity showed significance difference between the
scores of mental health by sex. This was consistent with a
previous study that reports psychological issues are more
prevalent among women.27 There were differences among the
scores of physical function, role limitation, social function, and
pain dimensions by age and history of disease. The previous
study also shows the same result.1,29,33 The scores of physical
function, role limitation, and pain were significantly different by
education level and marital status. The result was consistent
with the study of Shafie et al, which shows differences among
all dimensions of the EQ-5D by education level and marital
status.27 Meanwhile, there was no significant score difference
among all dimensions of SF-6D by occupation and income level.
A study by Marra et al34 comparing the SF-6D with several
specific instruments (Rheumatoid Arthritis Quality of Life
Questionnaire and Health Assessment Questionnaire) reports
that among 313 patients with rheumatoid arthritis, the SF-6D
can differentiate severity categories of rheumatoid arthritis,
although specific instruments are more sensitive. A study on
167 patients of systemic lupus erythematosus shows that the
EQ-5D and SF-6D can differentiate patient group by severity of
disease.35 However, in general population, the SF-6D is more
sensitive than the EQ-5D in detecting differences between
groups. A study by Davison et al36 on 185 patients with stages 3
and 4 chronic liver failure shows that the SF-6D can differen-
tiate patients with upper scale range with smaller ceiling effect,
as well as patient groups by severity (predialysis vs dialysis)
and symptoms of depression.36
The result of reliability test-retest of the SF-6D using Spearman
rank correlation had good correlation for each domain (ie, 0.577-
0.819; .0.5). The Cronbach a coefficient score is 0.752 (r .0.7)
with correlation among items being 0.698 to 0.750, showing that
the SF-6D was reliable for measuring HRQOL. The reliability of the
SF-6D has been tested at various settings with varying results.
Khana et al37 report that the SF-6D is reliable for patients with
systemic sclerosis (intraclass correlation coefficient 0.82), whereas
the reliability test–retest by Boonen et al38 on ankylosing
210 VALUE IN HEALTH REGIONAL ISSUES
spondylitis patients show moderate correlation (intraclass corre-
lation coefficient 0.68). A study on an urban population in China
shows that the reliability test–retest result of the SF-6D is reliable
(r = 0.787).33
The limitations of this study are that it was only conducted in
Yogyakarta city and did not use a random sampling method, so
that it cannot be generalized to the population of Indonesia.
Second, the numbers between categories in the sociodemographic
of respondents are not proportional, so that it could not differ-
entiate their effects on the validity of the SF-6D. Third, re-
spondents were the general populations, so that they could not
represent the health status that can be used to determine the
effect of disease on the validity of measuring instruments.
Conclusions
The SF-6D questionnaire has been translated into a Bahasa
Indonesian version. The SF-6D questionnaire is valid and reliable,
which is indicated by the reliability coefficient of 0.725 and the
correlation among items ranging from 0.698 to 0.750. Known
group validity shows that the SF-6D could differentiate utility
scores by age group and history present illness.
Acknowledgments
Source of financial support: Support provided by the Directorate
General of Resources for Science Technology and Higher Educations.
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