Use of structural equation modeling to test the construct validity of the SF-36 Health Survey in ten countries: Results from the IQOLA Project

Susan D. Keller, John E. Ware, Peter M. Bentler, Neil K. Aaronson, Jordi Alonso, Giovanni Apolone, Jakob B. Bjorner, John Brazier, Monika Bullinger, Stein Kaasa, Alain Leplège, Marianne Sullivan, Barbara Gandek

Research output: Contribution to journalArticlepeer-review


A crucial prerequisite to the use of the SF-36 Health Survey in multinational studies is the reproduction of the conceptual model underlying its scoring and interpretation. Structural equation modeling (SEM) was used to test these aspects of the construct validity of the SF-36 in ten IQOLA countries: Denmark, France, Germany, Italy, the Netherlands, Norway, Spain, Sweden, the United Kingdom, and the United States. Data came from general population surveys fielded to gather normative data. Measurement and structural models developed in the United States were cross-validated in random halves of the sample in each country. SEM analyses supported the eight first-order factor model of health that underlies the scoring of SF-36 scales and two second-order factors that are the basis for summary physical and mental health measures. A single third-order factor was also observed in support of the hypothesis that all responses to the SF-36 are generated by a single, underlying construct - health. In addition, a third second-order factors, interpreted as general well-being, was shown to improve the fit of the model. This model (including eight first-order factors, three second- order factors, and one third-order factor) was cross-validated using a holdout sample within the United States and in each of the nine other countries. These results confirm the hypothesized relationships between SF- 36 items and scales and justify their scoring in each country using standard algorithms. Results also suggest that SF-36 scales and summary physical and mental health measures will have similar interpretations across countries. The practical implications of a third second-order SF-36 factor (general well-being) warrant further study.

Original languageEnglish
Pages (from-to)1179-1188
Number of pages10
JournalJournal of Clinical Epidemiology
Issue number11
Publication statusPublished - Nov 1998


  • Confirmatory factor analysis
  • Cross-cultural comparison
  • Health status indicators
  • SF-36 Health Survey
  • Structural equation modeling

ASJC Scopus subject areas

  • Medicine(all)
  • Public Health, Environmental and Occupational Health
  • Epidemiology

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