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Health Measurement Scales

Encyclopedia of Public Health:

Health Measurement Scales

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Because health is an abstract concept it cannot be measured directly using a mechanical scale asweight or length are measured. Instead, indicators of health have to be selected, and some form

of numerical judgement applied to quantify or "scale" these. For example, if health is defined interms of physical, mental, and social well-being, several indicators of each of these themes willtypically be selected and a scoring system for rating a person on each indicator will be devised.Finally, a second scoring system is developed to represent the relative importance of thephysical, mental, and social areas in the final rating, or health measurement scale.

The indicators included in such a scale may be recorded mechanically as in a treadmill test, orthey may derive from expert judgment as in a physician's assessment of a symptom.Alternatively, they may be recorded via self-ratings, as in a patient's replies to a disabilityquestionnaire. Most indicators of physical or mental health assess the intensity, duration, orfrequency of symptoms. The application of a numerical rating scale is often quite simple (as incounting a patient's arthritic joints). Alternatively, scores may be derived from sophisticated

experimental scaling protocols, such as the Time Trade-off or the Standard Gamble, whichrepresent the severity of a disabling condition by showing how many years of life a person withthat condition would be willing to lose in order to return to full health for his or her remainingyears.

Because of the complexity of developing a reliable and valid health measurement, there has beena steady growth over the past half century in the range of standardized health measurementscales that are available for general use. Using the same instrument in separate studies enablesdirect comparisons to be drawn among them. The current repertoire of health measurementsnumbers in the hundreds, and these have been described in several books. These ready-madehealth measurement scales may be classified by (1) their topic, (2) their scope, (3) their purpose,or (4) their design.

1. Measurement scales exist for the majority of common diagnoses, as well as for broader-ranging themes such as disability or health-related quality of life. Measures range fromthose that focus on a particular organ system (vision, hearing), to methods concernedwith a diagnosis (anxiety or depression scales), then to scales that measure broadersyndromes (emotional well-being), to measurements of overall health and, broadest of all,to measures of quality of life.

2. Scales may be generic or specific. The latter may be designed for a particular disease(such as a quality-of-life scale for cancer), but can also be specific to a particular type of
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person (women's health measures, patient satisfaction scales) or to an age group (childhealth indicators). Specific instruments are generally intended for clinical application andare designed to be sensitive to change following treatment. Generic instruments, such asthe Sickness Impact Profile or the European Quality of Life Scale, permit comparisonsacross disease categories and are used in evaluating systems of care.

3. The purposes of measurement scales include diagnosis, prediction, and evaluation.Diagnostic scales (such as the Cambridge Mental Disorders of the Elderly Examinationor CAMDEX) collect a wide variety of information from self-report and clinical ratings,and process these using algorithms that suggest differential diagnoses. Prognosticmeasures include Health Risk Appraisal measures (which estimate the odds that a personwith certain characteristics will die from specified causes within a given time frame), ormethods such as the Functional Assessment Inventory, which estimate whether a patientwill be able to live independently in the community following rehabilitation. Finally,evaluative indices measure change over time and are used to indicate the impact oroutcomes of care. This category forms by far the largest group of instruments, andincludes both generic and disease-specific outcome measures.

4. Measurement scales may be grouped into rating scales and questionnaires; there is alsothe distinction between health indexes and health profiles. Cutting across thesecategories, there is the distinction between subjective and objective measures. Ratingscales refer to methods in which an expert, typically a clinician, assesses defined aspectsof health; an example is the Hamilton Rating Scale for Depression. In self-assessedmeasurement scales, set questions are answered by the person being rated. Both areexamples of subjective measures, in which human judgment (by clinician or patient) isinvolved in the assessment. Objective measures involve no judgment in the collection ofinformation (although judgment may be required in its interpretation). Subjective healthmeasurements hold several advantages. They extend the information obtainable frommorbidity statistics or physical measures by describing the quality rather than merely thequantity of function. They give insights into matters of human concern such as pain,

suffering, or depression that cannot be inferred solely from physical measurements orlaboratory tests, and they do not require invasive procedures or expensive laboratoryanalyses. Measures of either type can be summarized as a single index score, or as aprofile of scores. Supporters of the profile approach argue that health or quality of life isinherently multidimensional and scores on different dimensions should be presentedseparately. Conversely, index scores allow ready comparisons of the impact of differentmedical conditions, useful, for example, in economic evaluations of health care.

Health measurement scales have become firmly established as a routine part of evaluating newtherapies and in planning care. Newer and more sophisticated techniques for scale developmentare being applied to health measurement scales, and a discipline of health measurementequivalent to econometrics or psychometrics is beginning to appear. Future advances will

include further consolidation of the repertoire of health measurement scales, including thereplacement of some outdated methods with newer instruments. Population norms are graduallybeing developed that will permit fuller interpretation of scores against reference standards.

(SEE ALSO:Assessment of Health Status;Health Risk Appraisal;Life Expectancy and LifeTables)

Bibliography
http://www.answers.com/topic/assessment-of-health-statushttp://www.answers.com/topic/health-risk-appraisalhttp://www.answers.com/topic/life-expectancyhttp://www.answers.com/topic/life-expectancyhttp://www.answers.com/topic/assessment-of-health-statushttp://www.answers.com/topic/health-risk-appraisalhttp://www.answers.com/topic/life-expectancyhttp://www.answers.com/topic/life-expectancy


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Bowling, A. (1995). Measuring Disease: A Review of Disease-specific Quality of LifeMeasurement Scales. Buckingham, England: Open University Press.

McDowell, I., and Newell, C. (1996). Measuring Health: A Guide to Rating Scales andQuestionnaires. New York: Oxford University Press.

Spilker, B., ed. (1990). Quality of Life Assessment in Clinical Trials. New York: Raven Press.

Wilkin, D.; Hallam, L.; and Doggett, M. A. (1992). Measures of Need and Outcome for PrimaryHealth Care. Oxford: Oxford University Press.

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Healthy Measurementwww.RightHealth.comRelax. Take A Deep Breath. Healthy Measurement

MEASUREMENT OF HEALTH STATUS" Health " is a multi-dimensional concept that is usually and measured in terms of: l)

absence of physical pain, physical disability, or a condition that is likely to cause

death, 2) emotional well-being, and 3) satisfactory social functioning. Some have a

dvocated including the quality of an individual's physical environment in the

definition of health, but this dimension is not at present included in the most widely

used measures of health.

There is no single " standard " measurement of health status for individuals or population groups.Individual health status may be measured by an observer (e.g., a physician), who performs an

examination and rates the individual along any of several dimensions, including presence orabsence of life-threatening illness, risk factors for premature death, severity of disease, andoverall health. Individual health status may also be assessed by asking the person to reporthis/her health perceptions in the domains of interest, such as physical functioning, emotionalwell-being, pain or discomfort, and overall perception of health. Although it is theoreticallyattractive to argue that the measurement of health should consist of the combination of both anobjective component plus the individual's subjective impressions, no such measure has beendeveloped.

The health of an entire population is determined by aggregating data collected on individuals.The health of an individual is easier to define than the health of a population. Once the definitionof optimum health for the individual is agreed upon, health status can be placed along a

continuum from perfect health to death. No comparable scale exists for whole populations. Whatis the population-level equivalent of death? (Keep in mind that it is unusual for entirepopulations to die.) What is the population-level equivalent of optimum health?

In the absence of comprehensive or absolute measures of the health of a population, the averagelifespan, the prevalence of preventable diseases or deaths, and availability of health servicesserve as indicators of health status. Judgments regarding the level of health of a particularpopulation are usually made by comparing one population to another, or by studying the trendsin a health indicator within a population over time.

Some commonly used measures of population health status are:

Morbidity Measures

Incidence rate = Number of new cases of a disease occurring in thepopulation during a

specified time period____________________________________________________________

___________Number of persons exposed to risk of developing the disease

duringthat period of time
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Prevalence = Number of cases of disease present in the population at aspecified

period of time________________________________________________________________

________Number of persons at risk of having the disease at that

specified time

The above ratios are multiplied by 1,000 or 100,000 to yield statistics that are more readilyinterpretable. Click here for yourAssignment"

Mortality Measures

Death Rate = Number of deaths in the population during a specified timeperiod

___________________________________________________________________

The number of persons in the population during the specifiedtime

period

The denominator is usually defined as the number of persons in the population at the midpoint ofthe time period (usually 12 months). The rate is multiplied by 1,000 or 100,000 for ease ofinterpretation. Death rates, or mortality rates can be calculate d for deaths from specific causes,and for specific age and gender groupings.

Death rates can be calculated for all causes combined, specific causes, and particular age-sexgroups.

In order to compare mortality rates across different population groups or time periods, the ratesmust be " standardized " to a population with the same age structure. For example, if you areinterested in comparing mortality from colon cancer in Hispanics and non-Hispanics in the U.S.in 1970 and 1990, the " crude " death rates in the two populations at two different points in time

will not be comparable. The Hispanic population is likely to be younger on average than the non-Hispanic population at both time points, and the median age of both populations can be expectedto have increased over the 20 year time interval. Since the prevalence of colon cancer increaseswith age, unadjusted mortality rates would underestimate the prevalence in Hispanics at bothpoints in time, and the prevalence would be underestimated for both populations in 1970compared to 1990. In order to avoid errors in interpretation, mortality rates must be adjusted to acommon population with a known age structure. The choice of standard population is arbitrary.When reviewing mortality statistics, always check the footnotes of tables for information on thereference population that was used to standardize the mortality rates.

Table 1

Death Rates for Diseases of the Heart in Persons45 Years and Over, 1988-1990

Deaths per 100,000 Resident Population

Ethnic Group Age-Adjusted Rate(*) Crude Rate


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males results in a decrease in life expectancy at birth compared to males in the U.S. andNorway? What causes of death could account for these mortality differences?

TABLE 2

MALES

Life Norway U.S. MexicoExpectancy 1990 1990 1989

Age 0 74.1 71.9 69.3

Age 1 73.6 71.7 69.9

Age 15 59.8 58.0 56.7

Age 45 31.4 30.8 30.2

Age 65 14.9 15.2 15.0

Source: World Health Organization: World HealthStatistics Annual, 1993.

Assignment

Exercise 1

Use the following numbers to calculate the annual incidence rate and 1991

prevalence of AIDS per 100,000 population in Hispanics in Houston, Texas. For ease

of calculation, assume that cases alive at the beginning of 1991 live for the entire

year.

Total estimated Hispanic population in 1991: 452,780

Total cases of AIDS in Hispanics reported from 1981- 1990: 850

Total new cases of AIDS reported in Hispanics in 1991: 95

Total deaths from AIDS in Hispanics from 1981 (first year reporting began) to 1990: 595

Click here to see the Answer

Exercise 2

Examine the age adjusted and crude death rates due to heart disease in 1988-1990

reported by the National Center for Health Statistics. What effect does ageadjustment have on all of the rates? Which ethnic group has the highest age

adjusted heart disease death rate? Which group the lowest?

A common way to compare the probability of death or disease in two groups is to calculate theratio of the measures of disease frequency in the groups. This ratio is referred to as the " relativerisk." For example, if the incidence rate of breast cancer in Hispanic women is 20/100,000compared to 45/100,000 in Black women, the relative risk (RR) for breast cancer in Black
http://www.rice.edu/projects/HispanicHealth/HealthStatus/Answer1.htmlhttp://www.rice.edu/projects/HispanicHealth/HealthStatus/Answer1.htmlhttp://www.rice.edu/projects/HispanicHealth/HealthStatus/Answer1.html


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women compared to Hispanic women is 2.25. Black women can be said to have a 225% excessrisk of developing breast cancer than Hispanic women. Calculate the relative risk of heart diseasedeath in whites compared to Hispanics using the figures in Table 1. Calculate the RR's using firstthe crude death rates, then the age adjusted death rates. What happens to the RR when you usethe age adjusted death rates?

Click here to see the Answer

Hispanic Health Home Page
http://www.rice.edu/projects/HispanicHealth/HealthStatus/Answer2.htmlhttp://www.rice.edu/projects/HispanicHealth/HealthStatus/Answer2.htmlhttp://riceinfo.rice.edu/projects/HispanicHealth/index.htmlhttp://www.rice.edu/projects/HispanicHealth/HealthStatus/Answer2.htmlhttp://riceinfo.rice.edu/projects/HispanicHealth/index.html

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