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 as
weight 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 in
terms of physical, mental, and social well-being, several indicators of each of these themes will
typically 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 the
physical, 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, or
they 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 disability
questionnaire. Most indicators of physical or mental health assess the intensity, duration, or
frequency of symptoms. The application of a numerical rating scale is often quite simple (as in
counting 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, which
represent the severity of a disabling condition by showing how many years of life a person with
that condition would be willing to lose in order to return to full health for his or her remaining
years.
Because of the complexity of developing a reliable and valid health measurement, there has been
a steady growth over the past half century in the range of standardized health measurement
scales that are available for general use. Using the same instrument in separate studies enables
direct comparisons to be drawn among them. The current repertoire of health measurements
numbers in the hundreds, and these have been described in several books. These ready-made
health 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 from
those that focus on a particular organ system (vision, hearing), to methods concerned
with a diagnosis (anxiety or depression scales), then to scales that measure broader
syndromes (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
 person (women's health measures, patient satisfaction scales) or to an age group (child
health indicators). Specific instruments are generally intended for clinical application and
are designed to be sensitive to change following treatment. Generic instruments, such as
the Sickness Impact Profile or the European Quality of Life Scale, permit comparisons
across 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 Examination
or CAMDEX) collect a wide variety of information from self-report and clinical ratings,
and process these using algorithms that suggest differential diagnoses. Prognostic
measures include Health Risk Appraisal measures (which estimate the odds that a person
with certain characteristics will die from specified causes within a given time frame), or
methods such as the Functional Assessment Inventory, which estimate whether a patient
will be able to live independently in the community following rehabilitation. Finally,
evaluative indices measure change over time and are used to indicate the impact or
outcomes of care. This category forms by far the largest group of instruments, and
includes both generic and disease-specific outcome measures.
4. Measurement scales may be grouped into rating scales and questionnaires; there is also
the distinction between health indexes and health profiles. Cutting across these
categories, there is the distinction between subjective and objective measures. Rating
scales refer to methods in which an expert, typically a clinician, assesses defined aspects
of health; an example is the Hamilton Rating Scale for Depression. In self-assessed
measurement scales, set questions are answered by the person being rated. Both are
examples of subjective measures, in which human judgment (by clinician or patient) is
involved in the assessment. Objective measures involve no judgment in the collection of
information (although judgment may be required in its interpretation). Subjective health
measurements hold several advantages. They extend the information obtainable from
morbidity statistics or physical measures by describing the quality rather than merely the
quantity of function. They give insights into matters of human concern such as pain,
suffering, or depression that cannot be inferred solely from physical measurements or
laboratory tests, and they do not require invasive procedures or expensive laboratory
analyses. Measures of either type can be summarized as a single index score, or as a
profile of scores. Supporters of the profile approach argue that health or quality of life is
inherently multidimensional and scores on different dimensions should be presented
separately. Conversely, index scores allow ready comparisons of the impact of different
medical conditions, useful, for example, in economic evaluations of health care.
Health measurement scales have become firmly established as a routine part of evaluating new
therapies and in planning care. Newer and more sophisticated techniques for scale development
are being applied to health measurement scales, and a discipline of health measurement
equivalent to econometrics or psychometrics is beginning to appear. Future advances will
include further consolidation of the repertoire of health measurement scales, including the
replacement of some outdated methods with newer instruments. Population norms are gradually
being developed that will permit fuller interpretation of scores against reference standards.
(SEE ALSO: Assessment of Health Status; Health Risk Appraisal; Life Expectancy and Life
Tables)
Bibliography
Bowling, A. (1995). Measuring Disease: A Review of Disease-specific Quality of Life
Measurement Scales. Buckingham, England: Open University Press.
McDowell, I., and Newell, C. (1996). Measuring Health: A Guide to Rating Scales and
Questionnaires. 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 Primary
Health Care. Oxford: Oxford University Press.
— IAN MCDOWELL

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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 or
absence of life-threatening illness, risk factors for premature death, severity of disease, and
overall health. Individual health status may also be assessed by asking the person to report
his/her health perceptions in the domains of interest, such as physical functioning, emotional
well-being, pain or discomfort, and overall perception of health. Although it is theoretically
attractive to argue that the measurement of health should consist of the combination of both an
objective component plus the individual's subjective impressions, no such measure has been
developed.
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 definition
of 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. What
is the population-level equivalent of death? (Keep in mind that it is unusual for entire
populations 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 average
lifespan, the prevalence of preventable diseases or deaths, and availability of health services
serve as indicators of health status. Judgments regarding the level of health of a particular
population are usually made by comparing one population to another, or by studying the trends
in 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 the
population during a
specified time period
____________________________________________________________
___________
Number of persons exposed to risk of developing the disease
during
that period of time
Prevalence = Number of cases of disease present in the population at a
specified
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 readily
interpretable. Click here for your Assignment"
Mortality Measures

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

period
________________________________________________________________
___
The number of persons in the population during the specified
time
period
The denominator is usually defined as the number of persons in the population at the midpoint of
the time period (usually 12 months). The rate is multiplied by 1,000 or 100,000 for ease of
interpretation. 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-sex
groups.
In order to compare mortality rates across different population groups or time periods, the rates
must be " standardized " to a population with the same age structure. For example, if you are
interested 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 expected
to have increased over the 20 year time interval. Since the prevalence of colon cancer increases
with age, unadjusted mortality rates would underestimate the prevalence in Hispanics at both
points in time, and the prevalence would be underestimated for both populations in 1970
compared to 1990. In order to avoid errors in interpretation, mortality rates must be adjusted to a
common 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 the
reference population that was used to standardize the mortality rates.

Table 1
Death Rates for Diseases of the Heart in Persons
45 Years and Over, 1988-1990

Deaths per 100,000 Resident Population

Ethnic Group Age-Adjusted Rate(*) Crude Rate

White 553.6 950.7

Black 779.3 1,031.5

Asian/Pacific Islander 290.1 331.1

American Indian or Alaskan Native 393.5 453.6

Hispanic 383.2 461.9

(*)Age adjusted by the direct method to the U.S. population enumerated in

1940.
Source: National Center for Health Statistics: Health United States 1992,
Table 31.

Click here for your Assignment

The age adjusted relative risk of heart disease death for whites compared to Hispanics is much
lower than the crude relative risk. This reflects differences in the age structure of the two
populations. Failure to adjust for this age difference would overestimate the differences in heart
disease mortality between the two population groups.

Other Indicators
Infant mortality rate = Number of deaths to infants under age 1 X
1,000
_________________________________________________
Total live births
The infant mortality rate is a widely used indicator of a population's health status
because it is associated with education, economic development, and availability of
health services.

Life expectancy:

The average number of additional years a person can expect to live from a
given age onward.

Life expectancy at birth is the statistic usually calculated for population groups. Life expectancy
is calculated by apply age and sex-specific mortality rates from the population under study to a
hypothetical birth cohort of 100,000 individuals. Life expectancy is a theoretical measure and
can change for an individual with changing trends in disease frequency in the population and
with individual behavioral changes. Lower life expectancy in developing countries is usually a
result of high infant mortality. Once individuals reach adulthood, their life expectancy tends to
be comparable across different population groups.
Table 2 contains recent average life expectancy estimates at birth, 1 year, 15 years, 45 years and
65 years for males in three different countries. Notice that males born in Mexico in 1989 can
expect to live an average of 69.3 years at birth, compared to 74.1 years for Norwegians and 71.9
years for U.S. males. In what age group does it appear that the mortality experience of Mexican
males results in a decrease in life expectancy at birth compared to males in the U.S. and
Norway? What causes of death could account for these mortality differences?

TABLE 2

MALES

Life Norway U.S. Mexico

Expectancy 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 Health

Statistics 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 age
adjustment 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 the
ratio of the measures of disease frequency in the groups. This ratio is referred to as the " relative
risk." For example, if the incidence rate of breast cancer in Hispanic women is 20/100,000
compared to 45/100,000 in Black women, the relative risk (RR) for breast cancer in Black
women compared to Hispanic women is 2.25. Black women can be said to have a 225% excess
risk of developing breast cancer than Hispanic women. Calculate the relative risk of heart disease
death in whites compared to Hispanics using the figures in Table 1. Calculate the RR's using first
the crude death rates, then the age adjusted death rates. What happens to the RR when you use
the age adjusted death rates?
Click here to see the Answer

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