Short Form 36 (SF-36)

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Tool Description

  • Generic health status measure that was introduced in 1992 and has been translated into various languages and is used world-wide.
  • Designed to be applied to all health conditions and assess health concepts which represent basic human values and were relevant to a person’s functional status and well-being.
    • contains 36 questions covering eight domains:
      1) Physical functioning
      2) Role limitations due to physical health problems
      3) Bodily pain
      4) General health
      5) Vitality
      6) Social functioning
      7) Role limitations due to emotional problems
      8) Mental health
      The responses are based on a Likert scale. Both standard (4 week) and acute (1 week) recall versions are used.  Version 2 of the SF-36 was released in 1996 and some modifications were made to the format, the wording of the questions and to the response options.

ICF Domain:

Quality of Life.

Number of Items:

36

Brief Instructions for Administration & Scoring

Administration:

  • Administered by interviewer or self-administered.

Equipment: None.

Scoring:

  • The manual (which must be purchased) has a scoring algorithm to transform item scores to a 0-100 scoring system.
  • Norm based scoring, where the mean score for the general population is 50 with a standard deviation of 10, is also used (scoring algorithm in manual).
  • The SF-36 can also be scored using two summary scores, a physical and a mental component score, which are norm based.

Interpretability

MCID: not established in SCI, but for a sample of patients with osteoarthritis of the lower extremities (n=142, mean age: 65.1 yrs, 70.5% female, 61.5% had knee osteoarthritis, 35.2% used NSAIDS or analgesics):

SF-36 subscales:

MCID for worsening

MCID for improvement

Bodily pain

7.2

7.8

Physical function

5.3

3.3

Physical component summary

2.0

2.0

Reference: Angst et al. 2001. “Smallest detectable and minimal clinically important differences of rehabilitation intervention with their implications for required sample sizes using WOMAC and SF-36 quality of life measurement instruments in patients with osteoarthritis of the lower extremities” Arthritis Care & Research, 45(4),  384–391.

SEM & MDC:
SF-36 score SEM and MDC (calculated from data in Lin et al. 2007):

SF-36 Subscales:

SEM

MDC

Physical functioning

21.4

59.4

Role physical

14.7

40.8

Bodily pain

7.4

20.6

General health

7.9

21.8

Vitality

4.6

12.7

Social functioning

5.9

16.3

Role emotional

4.1

11.3

Mental health

7.4

20.6

  • There is published data and norms available for some health conditions as well as for the general population (Canada and United States).
  • Higher scores indicate higher levels of health.
  • Further research is needed on using the SF-36 for individuals with SCI to understand how they are answering the questions to ensure the data is valid.
  • Normative data for the SCI population have not been reported at this time
  • Published data on the SCI population is available for comparison (see Interpretability section of the Study Details sheet).

Languages:

The SF-36 has been translated into over 50 languages.

Training Required:

None.

Availability:

Permission to use the tools must be obtained from Quality Metric at www.qualitymetric.com. There is a cost to buy the manuals as well as to use the tools (depending on how they will be used).

Clinical Considerations

  • The SF-36 is the most widely used health survey and has been used in SCI. It has been used extensively to discriminate, evaluate and predict outcomes in various health conditions, but more work is required to study the validity of the questions and the proposed modifications to the questions for SCI patient population.
  • The questions related to walking and climbing stairs are seen to be insensitive to individuals with a complete SCI.

Measurement Property Summary

# of studies reporting psychometric properties: 11

Reliability:

  • Internal consistency ranges from moderate to high for total SF-36 (Cronbach’s a=0.82) and subscales:
    • Physical Functioning (Cronbach’s a=0.91-0.98)
    • Role Physical (Cronbach’s a=0.94)
    • Bodily Pain (Cronbach’s a=0.79)
    • General Health (Cronbach’s a=0.79-0.82)
    • Vitality (Cronbach’s a=0.76)
    • Social Functioning (Cronbach’s a=0.72)
    • Role Emotional (Cronbach’s a=0.89)
    • Mental Health (Cronbach’s a=0.78)
  • Inter-rater and intra-rater reliability ranges from moderate to high for the SF-36 subscales: (Inter-rater ICC, intra-rater ICC)
    • Physical Functioning (0.67, 0.71)
    • Role Physical (0.90, 0.89)
    • Bodily Pain (0.70, 0.87)
    • General Health (0.41, 0.87)
    • Vitality (0.86, 0.93)
    • Social Functioning (0.52, 0.93)
    • Role Emotional (0.98, 0.99)
    • Mental Health (0.57, 0.77)

[Forchheimer et al. 2004, King & Roberts 2002, Lin 2007, Luther et al. 2006, Van Leeuwen et al. 2012]

Validity:

  • Correlation of the SF-36 mental summary is high with Behavioural Risk Factor Surveillance System items (Pearson’s r=-0.650 to -0.761), low with the Quality of WellBeing (Pearson’s r=0.116), and low with the Instrumental Activities of Daily Living (Pearson’s r=0.262).
  • Correlation of the SF-36 physical summary is moderate with the Behavioural Risk Factor Surveillance System items (Pearson’s r=-0.458 to -0.489), the Quality of WellBeing (Pearson’s r=0.417) and the Instrumental Activities of Daily Living (Pearson’s r=-0.357)
  • The ability of the SF-36 to discriminate among subgroups with respect to age, education, marital status, employment, time since injury, level of injury, and self-care ability was tested using the Mann-Whitney U-test.
  • The domains of the SF-36 had significant discriminant validity between employment and self-care ability; the discriminant ability differed with other characteristics. Overall, the SF-36 domains significantly discriminated between subgroups in terms of 2-4 characteristics.

[Forchheimer et al. 2004, King & Roberts 2002, Lin 2007, Luther et al. 2006, Van Leeuwen et al. 2012, Andresen et al. 1999, Bonne-Lee et al. 2008, Miller et al. 2008, Raichle et al. 2006, Anton et al. 2006, Horner-Johnson et al. 2010]

Responsiveness:

  • Significantly lower scores for individuals with SCI than the nondisabled group were reported on the Physical Functioning, Bodily Pain and Role-Physical domains.
  • However, all Vitality subscale items showed significant positive differential functioning for people with SCI when controlling for total physical health scores.

[Lin 2007, Bonne-Lee et al. 2008, Horner-Johnson et al. 2010]

Floor/ceiling effect:

  • Floor effects and ceiling effects reported for the SF-36.
  • 3 subscales (role physical, social functioning, role emotion) exhibited ceiling effects between 22.5 and 75.3%.
  • 2 subscales (physical functioning and role physical) exhibited floor effects 24.2% and 36.3%, respectively.

[King & Roberts 2002, Van Leeuwen et al. 2012, Andresen et al. 1999, Lin 2007, Bonne-Lee et al. 2008]

Reviewer

Dr. Ben Mortenson, Brodie Sakakibara, John Zhu, Jeremy Mak

Date Last Updated:

Mar 16, 2017

Download the measure

Download Worksheet:
Permission to use the tools must be obtained from Quality Metric at www.qualitymetric.com. There is a cost to buy the manuals as well as to use the tools (depending on how they will be used).

Video

n/a

Scoring

n/a

Equipment Needed

SF-36:

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King JT and Roberts MS. Validity and reliability of the Short Form-36 in cervical spondylotic myelopathy. J Neurosurg (Spine 2), 2002; 97:180-185.
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http://www.ncbi.nlm.nih.gov/pubmed/17909558

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