Psychometric Characteristics of the Health Survey Questionnaire (SF-36) for Evaluation of Multiple Sclerosis: Psychometric Evaluation in Iranian Patients

Document Type : Original Article


1 Ph.D Student in Clinical Psychology.

2 Associate professor of Psychology

3 Department of Psychology, University of Guilan, Rasht, Iran.

4 University of Isfahan, Isfahan, Iran.


Background and Objectives: Quality of lifeassessment as an outcomes measure in multiple sclerosis (MS) can have a key role in identifying adverse effects of the disease and the impact of different treatments in the progress and improvement of patients; Hence, the aim of this study was to examine the psychometric characteristics Persian version of the health survey questionnaire (SF-36) in the MS.
Subjects and Methods: One hundred and sixty two patients were selected by consecutive method. SF-36 was evaluated for its internal consistency reliability, construct validity, concurrent, predictive and differentiation. In order to achieve this aim, the Fatigue Severity Scale and the 21-question (DASS-21) of depression, anxiety and stress scale were used.
Results: Internal consistency of SF-36 subscales except social functioning and emotional problems (α= 0.42 to 0.93) were favorable. Analysis of the validity of the SF-36 showed that all of the questionnaire items had a strong positive correlation with subscales on their own (r=0.48 to 0.95); Each subscale had a strong and inverse correlation with the constructs of fatigue, depression, anxiety and stress (r= -0.27 to -0.71 ; P<0.001); SF-36 physical component predicted a significant proportion of the variance in score on fatigue (P<0.0001) and mental component also showed a significant proportion of the variance in scores on depression, anxiety and stress, even after controlling demographic confounding factors of age, sex, marital status and educational level (P<0.0001). The mean of all subscales was significantly greater in both groups of abnormal and fatigued patients than normal and nonfatigued patients.
Conclusion: Persian version of the SF-36 has good validity and reliability and could be used to assess the impact of MS outcomes on quality of life of patients.


1-Freeman JA, Hobart JC, Langdon DW, Thompson AJ. Clinical appropriateness: a key factor in outcome measure selection: the 36 item short form health survey in multiple sclerosis. J Neurol Neurosurg Psychiatry 2000Feb; 68(2): 150-6.
2-Patrick DL, Deyo RA. Generic and disease specific measures in assessing health status and quality of life. Med Care 1989Mar; 27(suppl 3): S217–32.
3-Dennison L, Moss-Morris R, Chalder T. A review of psychological correlates of adjustment in patients with multiple sclerosis. Clin Psychol Rev 2009Mar; 29(2): 141-53.
4-Kurtzke JF. Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS). Neurology 1983Nov; 33(11): 1444-52.
5-Nortvedt MW, Riise T, Myhr KM, Nyland HI. Quality of life in multiple sclerosis: measuring the disease effects more broadly. Neurology 1999Sep; 53(5): 1098-103.
6-Janardhan V, Bakshi R. Quality of life and its relationship to brain lesions and atrophy on magnetic resonance images in 60 patients with multiple sclerosis. Arch Neurol 2000Oct; 57(10):1485-91.
7-Baumstarck K, Boyer L, Boucekine M, Michel P, Pelletier J, Auquier P. Measuring the quality of life in patients with multiple sclerosis in clinical practice: a necessary challenge. Mult Scler Int 2013; 2013: 524894.
8-Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992Jun; 30(6): 473-83.
9-Vickrey BG, Hays RD, Harooni R, Myers LW, Ellison GW. A health-related quality of life measure for multiple sclerosis. Qual Life Res 1995Jun; 4(3): 187-206.
10-Wang SJ, Fuh JL, Lu SR, Juang KD. Quality of life differs among headache diagnoses: analysis of SF-36 survey in 901 headache patients. Pain 2001Jan; 89(2-3): 285-92.
11-Monzón MJ, Láinez MJ. Quality of life in migraine and chronic daily headache patients. Cephalalgia 1998Nov; 18(9): 638-43.
12-Guitera V1, Muñoz P, Castillo J, Pascual J. Quality of life in chronic daily headache: a study in a general population. Neurology 2002Apr; 58(7): 1062-5.
13-Autret A1, Roux S, Rimbaux-Lepage S, Valade D, Debiais S. West Migraine Study Group. Psychopathology and quality of life burden in chronic daily headache: influence of migraine symptoms. J Headache Pain 2010Jun; 11(3): 247-53.
14-Qin Z1, Zhang L, Sun F, Fang X, Meng C, Tanner C, "et al". Health related quality of life in early Parkinson's disease: impact of motor and non-motor symptoms, results from Chinese levodopa exposed cohort. Parkinsonism Relat Disord 2009Dec; 15(10): 767-71.
15-Kauhanen ML, Korpelainen JT, Hiltunen P, Nieminen P, Sotaniemi KA, Myllylä VV. Domains and determinants of quality of life after stroke caused by brain infarction. Arch Phys Med Rehabil 2000Dec; 81(12): 1541-6.
16-Taillefer SS, Kirmayer LJ, Robbins JM, Lasry JC. Psychological correlates of functional status in chronic fatigue syndrome. J Psychosom Res 2002Dec; 53(6): 1097-106.
17-Patti F1, Cacopardo M, Palermo F, Ciancio MR, Lopes R, Restivo D, "et al". Health-related quality of life and depression in an Italian sample of multiple sclerosis patients. J Neurol Sci 2003Jul; 211(1-2): 55-62.
18-Merkelbach S1, Sittinger H, Koenig J. Is there a differential impact of fatigue and physical disability on quality of life in multiple sclerosis?. J Nerv Ment Dis 2002Jun; 190(6): 388-93.
19-Ware JE Jr, Snow KK, Kosinski M, Gandek B. SF-36 Health survey: manual and interpretation guide. Boston, Massachusetts: New England: The Health Institute, New England Medical Centre; 1993.
20-Asghari Moghaddam MA, Faghihi S. Validity and reliability of the health survey questionnaire (36 item Short Form) in two Iranian samples. J Daneshvar Rafter 2003; 10(1): 1-10 [In Persian].
21-Montazeri A, Goshtasebi A, Vahdaninia M, Gandek B. The Short Form Health Survey (SF-36): translation and validation study of the Iranian version. Qual Life Res 2005Apr; 14(3): 875-82.
22-Salehpoor G, Hosseininezhad M, Rezaei S. A preliminary path analysis: Effect of psychopathological symptoms, mental and physical dysfunctions related to quality of life and body mass index on fatigue severity of Iranian patients with multiple sclerosis. Iran J Neurol 2012; 11(3): 96-105.
23-Pakpour AH, Yekaninejad MS, Mohammadi NK, Molsted S, Zarei F, Patti F, "et al". Health-related quality of life in Iranian patients with multiple sclerosis: a cross-cultural study. Neurol Neurochir Pol 2009Nov-Dec; 43(6): 517-26.
24-Rafeeyan Z, Azarbarzin M, Moosa FM, Hasanzadeh A. Effect of aquatic exercise on the multiple sclerosis patients' quality of life. Iran J Nurs Midwifery Res 2010; 15(1): 43-7.
25-Laosanguanek N, Wiroteurairuang T, Siritho S, Prayoonwiwat N. Reliability of the Thai version of SF-36 questionnaire for an evaluation of quality of life in multiple sclerosis patients in multiple sclerosis clinic at Siriraj Hospital. J Med Assoc Thai 2011Feb; 94 (Suppl 1): S84-8.
26-Habibi M, Khodaei E, Moghadamzadeh A, Shamsedini S, Barekatain M. Psychometric properties and hierarchical factor structure of short form health survey scale (SF-36) in a non-clinical sample. J Res Behave Sci 2012; 10(6): 472-90 [In Persian].
27-Jafari H, Lahsaeizadeh S, Jafari P, Karimi M. Quality of life in thalassemia major: reliability and validity of the Persian version of the SF-36 questionnaire. J Postgrad Med 2008Oct-Dec; 54(4): 273-5.
28-Eshaghi SR, Ramezani MA, Shahsanaee A, Pooya A. Validity and Reliability of the Short Form- 36 Items Questionnaire as a Measure of Quality of Life in Elderly Iranian Population. Amer J Appl Sci 2006; 3(3): 1763-6.
29-Ghaem H, Borhani Haghighi A, Jafari P, Nikseresht AR. Validity and reliability of the Persian version of the multiple sclerosis quality of life questionnaire. Neurol India 2007Oct-Dec; 55 (4): 369-75.
30-Nogueira LA, Nóbrega FR, Lopes KN, Thuler LC, Alvarenga RM. The effect of functional limitations and fatigue on the quality of life in people with multiple sclerosis. Arq Neuropsiquiatr 2009; 67(3B): 812-7.
31-Pittion-Vouyovitch S, Debouverie M, Guillemin F, Vandenberghe N, Anxionnat R, Vespignani H. Fatigue in multiple sclerosis is related to disability, depression and quality of life. J Neurol Sci 2006Apr; 243(1-2): 39-45.
32-Chen K1, Fan Y, Hu R, Yang T, Li K. Impact of depression, fatigue and disability on quality of life in Chinese patients with multiple sclerosis. Stress Health 2013Apr; 29(2): 108-12.
33-Goksel Karatepe A, Kaya T, Günaydn R, Demirhan A, Ce P, Gedizlioğlu M. Quality of life in patients with multiple sclerosis: the impact of depression, fatigue, and disability. Int J Rehabil Res 2011Dec; 34(4): 290-8.
34-Lobentanz IS, Asenbaum S, Vass K, Sauter C, Klösch G, Kollegger H, "et al". Factors influencing quality of life in multiple sclerosis patients: disability, depressive mood, fatigue and sleep quality. Acta Neurol Scand 2004Jul; 110(1): 6-13.
35-Amato MP1, Ponziani G, Rossi F, Liedl CL, Stefanile C, Rossi L. Quality of life in multiple sclerosis: the impact of depression, fatigue and disability. Mult Scler 2001Oct; 7(5): 340 -4.
36-Dubayova T, Krokavcova M, Nagyova I, Rosenberger J, Gdovinova Z, Middel B, "et al". Type D, anxiety and depression in association with quality of life in patients with Parkinson's disease and patients with multiple sclerosis. Qual Life Res 2013Aug; 22(6): 1353-60.
37-Frühwald S, Löffler-Stastka H, Eher R, Saletu B, Baumhackl U. Relationship between symptoms of depression and anxiety and the quality of life in multiple sclerosis. Wien Klin Wochenschr 2001Apr; 113(9): 333-8 [In German].
38-Salehpoor Gh, Kafi SM, Rezaei S, Hosseininezhad M, Salehi I. The Relation between Fatigue Severity with Psychological Symptoms and Quality of Life in Multiple Sclerosis. Zahedan J Res Med Sci 2012Nov; 14(9): 80-6.
39. Salehpoor Gh, Kafi SM, Rezaei S, Hosseininezhad M, Salehi I. Depression and Sub- clinical Markers of Multiple Sclerosis. Armaghane Danesh 2014; 19(2): 146-60 [In Persian].
40-Nortvedt MW, Riise T, Myhr KM, Nyland HI. Quality of life as a predictor for change in disability in MS. Neurology 2000Jul; 55(1): 51-4.
41-Visschedijk MA, Uitdehaag BM, Klein M, van der Ploeg E, Collette EH, Vleugels L, "et al". Value of health-related quality of life to predict disability course in multiple sclerosis. Neurology 2004Dec; 63(11): 2046-50.
42-Guarnaccia JB, Aslan M, O'Connor TZ, Hope M, Kazis L, Kashner CM, "et al". Quality of life for veterans with multiple sclerosis on disease-modifying agents: Relationship to disability. J Rehabil Res Dev 2006Jan-Feb; 43(1): 35-44.
43-Benito-León J, Mitchell AJ, Rivera-Navarro J, Morales-González JM. Impaired health-related quality of life predicts progression of disability in multiple sclerosis. Eur J Neurol 2013Jan; 20(1): 79-86.
44-Baumstarck K, Pelletier J, Butzkueven H, Fernández O, Flachenecker P, Idiman E, "et al". Health-related quality of life as an independent predictor of long-term disability for patients with relapsing-remitting multiple sclerosis. Eur J Neurol 2013Jun; 20(6): 907-14, e78-9.
45-McDonald WI, Compston A, Edan G, Goodkin D, Hartung HP, Lublin FD, "et al". Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis. Ann Neurol 2001; 50(1): 121-7.
46-Krupp LB, LaRocca N, Muir-Nash J, Steinberg AD. The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol 1989; 46(10): 1121–3.
47-Salehpoor GH, Rezaei S, Hosseininezhad M. Psychometric Properties of Fatigue Severity Scale in Patients with Multiple Sclerosis. J Kerman Uni Med Scie 2013; 20(3): 263-78 [In Persian].
48-Lovibond SH, Lovibond PF. Manual for the depression anxiety stress scales (second edition). Sydney: Psychology Foundation; 1995.
49-Espinola-Nadurille M, Colin-Piana R, Ramirez-Bermudez J, Lopez-Gomez M, Flores J, Arrambide G, "et al". Mental disorders in Mexican patients with multiple sclerosis. J Neuropsychiatry Clin Neurosci 2010; 22(1): 63-9.
50-Samani S, Jokar B. Validity and reliability short-form version of the Depression, Anxiety and Stress. J Soc Sci Hum Shiraz Uni 2007; 26(3): 65-77 [In Persian].
51-Holmes W, Shea J. Performance of a new, HIV/AIDS-targeted quality of life (HAT-QOL) instrument in asymptomatic seropositive individuals. Qual Life Res 1997Aug; 6(6): 561–71.
52-Sullivan M, Karlsson J, Ware JE Jr. The Swedish SF-36 Health Survey-I. Evaluation of data quality, scaling assumptions, reliability and construct validity across general populations in Sweden. Soc Sci Med 1995Nov; 41(10): 1349-58.
53-Thomas S, Thomas PW, Nock A, Slingsby V, Galvin K, Baker R, "et al" . Development and preliminary evaluation of a cognitive behavioural approach to fatigue management in people with multiple sclerosis. Patient Educ Couns 2010Feb; 78(2): 240-9.
54-Valko PO, Bassetti CL, Bloch KE, Held U, Baumann CR. Validation of the fatigue severity scale in a Swiss cohort. Sleep 2008Nov; 31(11): 1601-7.
55-Tran TD, Tran T, Fisher J. Validation of the depression anxiety stress scales (DASS) 21 as a screening instrument for depression and anxiety in a rural community-based cohort of northern Vietnamese women. BMC Psychiatry 2013Jan; 13: 24.
56-Ware JE Jr, Gandek B. Methods for testing data quality, scaling assumptions, and reliability: the IQOLA Project approach. International Quality of Life Assessment. J Clin Epidemiol 1998Nov; 51(11): 945-52.
57-Bunnag C, Leurmarnkul W, Jareoncharsri P, Tunsuriyawong P, Assanasen P, Pawankar R. Quality of life assessment in Thai patients with allergic rhinoconjunctivitis using the SF-36 questionnaire (Thai version). Rhinology 2005Jun; 43(2): 99-103.
58-Lim LL, Seubsman SA, Sleigh A. Thai SF-36 health survey: tests of data quality, scaling assumptions, reliability and validity in healthy men and women. Health Qual Life Outcomes 2008; 6: 52.
59-Loge JH, Kaasa S, Hjermstad MJ, Kvien TK. Translation and performance of the Norwegian SF-36 Health Survey in patients with rheumatoid arthritis. I. Data quality, scaling assumptions, reliability, and construct validity. J Clin Epidemiol 1998Nov; 51(11): 1069-76.
60-Bullinger M. German translation and psychometric testing of the SF-36 Health Survey: preliminary results from the IQOLA Project, International Quality of Life Assessment. Soc Sci Med 1995Nov; 41(10): 1359-66.
61-Krittayaphong R, Bhuripanyo K, Raungratanaamporn O, Chotinaiwatarakul C, Chaowalit N, Punlee K, "et al". Reliability of Thai version of SF-36 questionnaire for the evaluation of quality of life in cardiac patients. J Med Assoc Thai 2000Nov; 83 (Suppl 2): S130-6.
62-Tseng HM, Lu JF, Gandek B. Cultural issues in using the SF-36 Health Survey in Asia: results from Taiwan. Health Qual Life Outcomes 2003Nov; 1: 72: 1-9.
63-Lam CL, Gandek B, Ren XS, Chan MS. Tests of scaling assumptions and construct validity of the Chinese (HK) version of the SF-36 Health Survey. J Clin Epidemiol 1998Nov; 51 (11): 1139-47.
64-Li L, Wang HM, Shen Y. Chinese SF-36 Health Survey: translation, cultural adaptation, validation, and normalisation. J Epidemiol Community Health 2003Apr; 57(4): 259-63.
65-Ren XS, Amick B 3rd, Zhou L, Gandek B. Translation and psychometric evaluation of a Chinese version of the SF-36 Health Survey in the United States. J Clin Epidemiol 1998Nov; 51 (11): 1129-38.
66-Watkins RE, Plant AJ, Sang D, O'Rourke T, Gushulak B. Development of a Vietnamese version of the Short form-36 Health Survey. Asia Pac J Public Health 2000; 12(2): 118-23.
67-Gandek B, Ware JE Jr, Aaronson NK, Alonso J, Apolone G, Bjorner J, "et al". Tests of data quality, scaling assumptions, and reliability of the SF-36 in eleven countries: results from the IQOLA Project, International Quality of Life Assessment. J Clin Epidemiol 1998Nov; 51(11): 1149-58.
68-Wagner AK, Gandek B, Aaronson NK, Acquadro C, Alonso J, Apolone G, "et al". Cross-cultural comparisons of the content of SF-36 translations across 10 countries: results from the IQOLA Project, International Quality of Life Assessment. J Clin Epidemiol 1998Nov; 51(11): 925-32.
69-Benito-León J1, Morales JM, Rivera-Navarro J. Health-related quality of life and its relationship to cognitive and emotional functioning in multiple sclerosis patients. Eur J Neurol 2002Sep; 9(5): 497-502.
70-Miller DM1, Rudick RA, Baier M, Cutter G, Doughtery DS, Weinstock-Guttman B, "et al". Factors that predict health-related quality of life in patients with relapsing-remitting multiple sclerosis. Mult Scler 2003Feb; 9(1): 1-5.
71-Gold SM, Schulz H, Mönch A, Schulz KH, Heesen C. Cognitive impairment in multiple sclerosis does not affect reliability and validity of self-report health measures. Mult Scler 2003Aug; 9(4): 404-10.
72-Riemsma RP1, Forbes CA, Glanville JM, Eastwood AJ, Kleijnen J. General health status measures for people with cognitive impairment: learning disability and acquired brain injury. Health Technol Assess 2001; 5(6): 1-100.
73-Goverover Y, Chiaravalloti N, DeLuca J. The relationship between self-awareness of neurobehavioral symptoms, cognitive functioning and emotional symptoms in multiple sclerosis. Mult Scler 2005Apr; 11(2): 203-12.
74-Benedict RH, Cox D, Thompson LL, Foley F, Weinstock-Guttman B, Munschauer F. Reliable screening for neuropsychological impairment in multiple sclerosis. Mult Scler 2004Dec; 10(6): 675-8.