TL;DR: Summary

✅ Available on Bravely Connect

The SF-36 is a self-report measure used to assess both physical and mental wellbeing. It consists of 36 questions on eight separate scales which ask clients about their physical health and pain, social functioning, and emotional/mental wellbeing. The eight scales were derived from common concepts found to be affected by disease and treatment in prior health surveys. Scores for these scales are standardized into values ranging from 0 to 100 with 50 representing average health. The SF-36 is limited in that it’s less indicative of real-life wellness when compared to longer measures. Other limitations include Western-centrism, less sensitivity for individuals with extreme scores of either mental or physical health, lower completion levels in older populations, and lack of a sleep variable. Research suggests that the SF-36 may be particularly useful for tracking treatment progress in individuals with depression. The SF-36 is one of the most widely used and researched measures with over 100 translations available.

Highlights

📏 Lengths: 36 questions (8-10 minutes)

📋 Administration: Self-Report

🎯 Uses: For monitoring client health status and health-related quality of life.

⚠️ Important Caveats: Doesn’t apply well to Asian populations

✅ Available in Bravely Connect? Yes

🌏 Culturally Applicable? Western-Centric

💬 Translations? 120+

The SF-36 Question type and length

The client is presented with 36 questions. The questions relate to a variety of time periods, and the answers are also all question-specific.

For the full list of questions, check out the measures on Bravely Connect, or follow the following link to the original unautomated version: SF-36

What does the SF-36 measure

The SF-36 measures health-related wellbeing, helping to reveal the health benefits produced by a wide range of different treatments—including mental health interventions. This measure has items assessing perceptions of physical health and pain, social functioning, and emotional/mental wellbeing.

The SF-36 may be especially helpful for recording treatment progress in individuals with depression. Three of the SF-36’s mental health measure’s scales assessing social functioning, the impact of one’s emotions on daily activities, and impressions of one’s own mental health have been shown to effectively indicate depression recovery resulting from talk therapy and pharmaceutical treatments (Ware, 2000).

SF-36 Factor structure

The questionnaire is broken down into eight scales, and these eight scales are broken down into two ‘summary measures’ of physical and mental health.

The physical health measure’s scales are:

• Physical functioning (10 items)

• Role-physical (4 items)

• Bodily pain (2 items)

• General health (5 items)

The mental health measure’s scales are:

• Vitality (4 items)

• Social functioning (2 items)

• Role-emotional (3 items)

• Mental health (5 items)

Factor analytic studies have confirmed that there are two factors in this questionnaire: physical health and mental health. These 2 factors account for 80-85% of the variance across multiple countries.

The history and theory behind the SF-36

The Short Form 36 was designed in 1988 as a self-report measure for functional health and well-being, released as a development form. It was designed with the aim of creating a brief and comprehensive measures of general health status. In the following year, the International Quality of Life Assessment project was established to validate, norm, and document the translations of the SF-36. In 1990 the standard version of the SF-36 was released.

The eight health concepts measured in the SF-36 were selected from many included within the Medical Outcomes Study, with these eight partly being chosen because they are the most common concepts found to be affected by disease and treatment based on other healthy surveys. This means that many of the items within the SF-36 are inspired by other measures that have been used since the 1970s and 1980s such as the General Psychological Well-Being Inventory and the Health Perceptions Questionnaire. The Medical Outcome Study’s researchers utilised questionnaire items from their study and developed a 149-item measure called the Functioning and Well-Being Profile, from which the SF-36 originally took its items and instructions. Subsequently, the standard form edited the wording of the items and instructions, as well as providing improvements in the format and scoring of the questionnaire.

The SF-36 is now one of the most widely used and researched measures, with the SF-36 found in over 4000 publications and having been used in 400+ randomised controlled clinical trials.

SF-36 Scoring Interpretation

Manual scoring of the SF-36 is more challenging than many other measures. This is because all of the scales’ scores are standardised using a scoring algorithm so that all of the scales range from 0 to 100. This allows for a direct comparison between the scales despite them having a different number of questions. It also allows clients to be compared to normative values, as a score of 50 on any scale is the average.

Who developed the measures, licensing and how to obtain the SF-36

The SF-36 was developed by Dr John E Ware, building upon an 18-item measure he previously developed alongside Cathy Donald Sherbourne and Allyson Ross Davies. The SF-36 debuted in the RAND Corporation Medical Outcomes Study in fall of 1990. RAND Corporation allows for public use of the SF-36 under the following terms and conditions:

1. Changes to the Health Survey may be made without the written permission of RAND. However, all such changes shall be clearly identified as having been made by the recipient.

2. The user of this Health Survey accepts full responsibility, and agrees to indemnify and hold RAND harmless, for the accuracy of any translations of the Health Survey into another language and for any errors, omissions, misinterpretations, or consequences thereof.

3. The user of this Health Survey accepts full responsibility, and agrees to indemnify and hold RAND harmless, for any consequences resulting from the use of the Health Survey.

4. The user of the 36-Item Health Survey will provide a credit line when printing and distributing this document acknowledging that it was developed at RAND as part of the Medical Outcomes Study.

5. No further written permission is needed for use of this Health Survey.

Please note that there are two versions of the SF-36. The SF-36v2 contains several reworded items, modifies the response scales for several items, and has different scoring methods. Licensure for the SF-36v2 must be purchased from QualityMetric. While the v2 modifications are intended to improve ease of scoring and simplify the item wording for respondents, the original version provided by Bravely Connect continues to be one of the most widely used measures in health research.

The SF-36 is available on Bravely Connect as part of our automated measures.

There are also well over 100 translations of the SF-36. If you find a version you’d like adding to Bravely Connect then just let us know here. There are also a wide range of SF-36s for specific physical health issues, populations, and at different lengths:

• SF-12

• SF-10 Health Survey for children

• SF-20

• SF-21

• SF-30

• SF-34 HIV

• SF-36 Arthritis Specific Index

• SF-36 Physical Functioning Scale (back-specific)

• SF-36 Veterans

• SF-38

• SF-39

• SF-8 Health Survey

• SF-56

• SF-6D

Limitations, biases and when you should/shouldn’t use the SF-36

The SF-36 was developed as a shorter version of the many longer health wellbeing scales, but it’s important to note that relative to the longer measures the SF-36 only performs at 80-90% when it comes to empirical validity in studies involving physical and mental health criteria. That said, this limitation should be weighed up against the fact that the SF-36 is 5-10 times shorter than many of these measures; respondent motivation has to be taken into account, too.

Another key point is that, as with many measures widely used, the SF-36 was developed in a Western country without consideration for cultural differences. One study found the SF-36 was generally acceptable as a measure in Asia, but there a number of reasons that the SF-36 is lacking for Asian populations:

• In Asian populations the social functioning scale correlated more highly with the mental health scale, potentially because the concept of social functioning does not translate well to some countries e.g. In collectivism, it is culturally unacceptable to use health problems as an excuse to avoid family or social gatherings

• While primarily a physical scale, the Bodily Pain scale does not have as strong an association with the physical dimension as was found in the US (Fukuhara et al., 1998).

• Although primarily a mental scale, the Role Emotional scale was not as purely associated with the mental component as in the US and Western Europe.

• The Vitality scale had a high correlation with the mental component and a low correlation with the physical component in both Taiwan and Japan. In the US, Vitality had a moderate to substantial association with both the mental and physical components. In Chinese medicine, "JingShen" (associated with the presence of vitality) is used to describe "mental well-being". So, this finding is unsurprising.

Another potential demographic limitation to consider when using the SF-36 concerns age. When self-administered, older populations (typically those 65 and over) are less likely to respond to all 36 questions of the measure, especially when those questions use language referring to work or strenuous physical activity. Some studies have found improved response rates in older populations when the questions were asked via face-to-face interview as opposed to being self-administered.

Scoring of the SF-36 is limited in that results from the mental and physical health measures counterbalance one another. Individuals who report poor physical health will appear to have scores reflecting higher levels of mental health, and those who report poor mental health will seem to have scores indicating higher levels of physical health. If one reports very high levels of physical health but low mental health or vice versa, the scores are calculated in such a way that the overall score will seem average, potentially obscuring low levels of physical or mental wellbeing if the other score is high.

As mentioned earlier, the SF-36 was developed in a Western country, and one study has demonstrated similar performance of the SF-36 among samples in nine Western European countries and the US. In these countries—Denmark, France, Germany, Italy, the Netherlands, Norway, Sweden, Spain, the UK, and the US—the physical and mental health measures’ scales were strongly associated with their respective dimensions. Translations of the SF-36 for these countries demonstrate construct validity similar to the English version.

One final limitation to note about the SF-36 is that although the measure intends to assess physical and mental wellbeing, it does not contain any questions about sleep.

As always, if you’ve found a measure you would like adding to Bravely Connect as an automated measure, just drop us a measure request here.