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The Short Form 36 (SF-36) Health Survey: Normative data for the Irish
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 The Short Form 36 (SF-36) Health Survey: normative data for the Irish population

The Short Form 36 (SF-36) Health Survey:

original paper

normative data for the Irish population

C Blake, MB Codd1, YM O’Meara2

School of Physiotherapy, Department of Epidemiology and Health Research1, Department of Medicine and
Therapeutics2, University College Dublin, Mater Misericordiae Hospital, Eccles Street, Dublin, Ireland

Abstract
Background Generic measures of quality of life have a wide application in health research. They mea-
sure disease impact by comparing scores in patient groups with a healthy population. They also facilitate
comparative studies between different patient groups. The SF-36 Health Survey quantifies respondents’
perceptions of their functioning in eight dimensions of daily life.
Aim The aim of this study was to set normative values for the SF-36 in the Irish population aged 18 years
and over.
Method A random sample of 800 subjects was drawn from the electoral register using the RANSAM
method of sampling.
Results Two hundred and ninety five (37%) valid questionnaires were returned for analysis. The SF-36
was found to have acceptable internal consistency and validity. Normative values for the total population
are presented, in addition to results for males and females across seven age groups. Ageing was associat-
ed with a decline in the physical dimensions of health.
Conclusions There was no evidence to suggest that there were significant differences in health status
between males and females, or between this Irish sample and the published norms for the US population.

Introduction the respondent’s perception of their performance in eight

Health is a subjective and multidimensional concept, defined
as ‘a state of complete physical, mental and social well-
being’.1 In recent years, consensus has been reached that
measurement of health and the effects of health interventions
must take account of the patient’s perspective of health sta-
tus and quality of life.2-4 The number of tools available to
measure quality of life continues to grow, with the develop-
ment of disease-specific and generic measurement instru-
ments. Disease-specific questionnaires may be more sensitive
to changes in their target population, but have limited appli-
cation to other populations.5 Generic questionnaires have a
wider applicability, allowing comparison between different
patient groups and facilitating comparison with the general
healthy population.6
The Short Form 36 (SF-36) is a generic measure of health
status and quality of life which was developed by the Rand
Corporation in the US during the 1970s.7,8 The instrument
was subsequently refined and used in the Medical Outcomes
Study.9 The SF-36 consists of 36 questions which evaluate
dimensions of daily life. These include physical function
(PF), role physical (RP), bodily pain (BP), general health
(GH), vitality (VT), social function (SF), role emotional
(RE) and mental health (MH). Responses from the SF-36 are
summed and then transformed to give eight scores with a 0-
100 scale where higher scores indicate better function in that
dimension. There is an additional unscaled single item asking
respondents about health changes over the past year and two
further summary measures of physical (PCS) and mental
(MCS) health can be calculated.10 The SF-36 has been exten-
sively tested and has proven to be a reliable, valid and sensi-
tive measure of health status in the general population and in
a variety of patient groups.8,11-18
Normative data exist for the SF-36 for both US and UK
populations,8,10,12,18 but no general population norms have
been published for the Republic of Ireland. The objective of
this study was to determine normative values for the SF-36
questionnaire from a random sample of the population aged
18 years and over in Ireland (n=2.6 million).19

Irish Journal of Medical Science • Volume 169 • Number 3 195

C Blake et al

Methods Table I: SF-36 Normative data, Ireland: socio-demographic

features Study group vs general population
Sampling frame
The sampling frame chosen for this study was the Study General Population
Electoral Register, which serves as a list of persons in Group over 18 yearsa
n (%) (%)
the State who are over 18 years of age. The method of
sampling used was RANSAM, a computer-based system, Age distribution
designed by the Economic and Social Research Institute 18-24 34 (12) 16
(ESRI) to draw random national and regional samples 25-34 53 (18) 20
from the Electoral Register.20,21 One important feature of 35-44 73 (25) 19
this method is equal probability of selection (epsem), 45-54 51 (17) 16
meaning that every elector had an equal chance of being 55-54 43 (15) 12
chosen. 65-74 21 (7) 9
In order to provide comparative data for collateral 75+ 20 (6) 7
studies, at least 200 valid responses were required.
Gender distribution
Given that a single-stage postal survey would be expect- Male 129 (44) 49.7
ed to yield a response rate of only 25-30%, it was esti- Female 166 (56) 50.3
mated that a sample size of 800 individuals was neces-
sary. To achieve this, 80 primary sampling units were Employment
randomly selected from the District Electoral Divisions Employedb 180 (97) 94c
and 10 persons were selected from each district, giving
a total sample size of 800 individuals. The SF-36 UK a. Derived from Census 1996 data. Population under 18 years excluded
from calculations, CSO 1997.19
language version was mailed to each individual accom-
b. Employment rate: Number of employed as % workforce (i.e. those
panied by a customised questionnaire to collect socio-
employed or seeking work).
demographic data and past medical history, a cover let- c. National employment rate (March-May 1999). Quarterly National
ter and a stamped addressed envelope. No substitution Household Survey, CSO 1999.23
was employed at sampling or fieldwork stages. Only one
mail shot was performed and all replies were anony-
mous. Results
Questionnaires were returned by 323 individuals giving a
Statistical analysis response rate of 40%. Of these, 28 were returned by the post
The data were processed using SPSS statistical software. office or were incomplete leaving 295 (37%) valid question-
Normative data for the eight multi-item scales are provided naires. There were 129 (44%) male and 166 (56%) female
in the form of means, standard deviations, medians and respondents. The socio-demographic profile of the group is
ranges broken down by age and gender. given in Table 1. The age distribution of the sample reflected
Validity is concerned with the extent to which an instru- the general population,19 with the greatest percentage of
ment truly measures the concept that it purports to mea- respondents coming from the 35-44 year age band.
sure. Threats to validity in questionnaires include underes- Employment rates were also found to be similar in the sample
timation and overestimation of true status by respondents. and in the general population.23
The SF-36 has, however, performed well in tests of content, Evaluation of internal consistency showed that Cronbach’s
construct and criterion validity.10,12,17 As neither collateral α co-efficients ranged from 0.81 to 0.92 (see Table 2), while
reports nor physiological measures were available to gauge examination of construct validity revealed that physical func-
validity in this study, construct validity was assessed by test- tion declined in magnitude with ageing (rho = -0.4,
ing a number of hypotheses. The first was that ageing p<0.001), mental health scores were lower in those reporting
would be associated with a decline in physical functioning, depression (n=29, p<0.0001). Those who were unemployed
the second that those reporting depression would have due to illness (n=11) reported poorer SF-36 scores in all
poorer mental health scores than those reporting no dimensions (p<0.05) than those unemployed for non-medical
depression and the third, that those unemployed due to ill- reasons (n=6).
ness would have poorer scores than the group unemployed Table 3 presents normative data for the total sample and for
for other reasons. male and female subgroups. No significant differences were
Differences between groups were assessed using the Mann found between the sexes in any of the SF-36 scales. Age-spe-
Whitney and Kruskall Wallis tests. Spearman’s rank correla- cific results for Table 2: SF-36 Normative data, Ireland:
tion was used to examine the relationship between age band males and Cronbach’s α statistic
and the physical function scale. females across
Reliability or consistency is concerned with random error SF-36 dimensions n a
the eight SF-
in measurement. In this study, the questionnaire was
36 dimensions
administered once only, making examination of test-retest Physical function 284 0.92
internal consistency impossible. Evaluation of this concept are presented Role physical 282 0.90
was therefore limited to assessment of internal consistency, in Figures 1a Bodily pain 295 0.93
using Cronbach’s α co-efficient.22 Cronbach’s α is an inter- to 1h. Several General health 275 0.81
item internal consistency co-efficient which measures the interesting Vitality 286 0.86
overall correlation between items in the scale. Internal con- trends were Social function 291 0.86
sistency is considered acceptable when the a co-efficient noted. Age- Role emotional 282 0.82
exceeds 0.7.8 related decline Mental health 283 0.82

196 Irish Journal of Medical Science • Volume 169 • Number 3

 The Short Form 36 (SF-36) Health Survey: normative data for the Irish population

Figure 1. SF-36 Normative data, Ireland: median scores for age and gender groups

Irish Journal of Medical Science • Volume 169 • Number 3 197

C Blake et al

Table 3: SF-36 Normative data, Ireland: scores for general population and males vs females

Total Male Female Significance

(n=295) (n=129) (n=166) level

Physical function Mean (sd) 83.20 (22.85) 81.72 (24.80) 84.32 (21.28) n/s
Median (Range) 95 (0-100) 90 (0-100) 95 (0-100)
Role physical Mean (sd) 80.50 (34.54) 82.08 (32.60) 79.32 (35.96) n/s
Median (Range) 100 (0-100) 100 (0-100) 100 (0-100)
Bodily pain Mean (sd) 77.57 (26.38) 78.82 (24.95) 76.59 (27.46) n/s
Median (Range) 84 (0-100) 84 (12-100) 84 (0-100)
General health Mean (sd) 73.82 (21.13) 73.59 (18.63) 73.99 (22.88) n/s
Median (Range) 77 (5-100) 77 (20-100) 82 (5-100)
Vitality Mean (sd) 64.77 (20.43) 66.91 (20.18) 63.16 (20.53) n/s
Median (Range) 70 (0-100) 70 (15-100) 70 (0-100)
Social function Mean (sd) 84.08 (23.09) 84.17 (25.11) 84.02 (21.50) n/s
Median (Range) 100 (0-100) 100 (0-100) 100 (0-100)
Role emotional Mean (sd) 83.22 (31.97) 85.68 (28.16) 81.37 (34.53) n/s
Median (Range) 100 (0-100) 100 (0-100) 100 (0-100)
Mental health Mean (sd) 77.84 (16.49) 79.67 (15.08) 76.45 (17.41) n/s
Median (Range) 80 (16-100) 82 (36-100) 80 (16-100)

in physical function and role physical scales was more marked
in males than females (see Figures 1a and 1b). Social function
scores remained high in older females, but decreased in older
males (see Figure 1f). Role emotional scores showed no
change with age, except for females aged over 75 years, who
reported a sharp decline in this dimension (see Figure 1).
Comparisons were made between this Irish sample and
the US population norms published by Ware et al, 1994. 10
Median scores in the physical and mental health summary
scales (PCS and MCS) were compared for all age groups,
but no significant differences were found. Figure 2 pre-
sents the data for the youngest (18-24 year) and oldest
(75+year) age groups. Comparison with normative data for
the UK population was not possible since age-specific
median scores have not been reported for the PCS and
MCS. 18
Discussion
These data present values for the eight dimensions of the SF-
36 health survey for a random sample of the Irish population.
The study was designed so that the sample drawn should be
unbiased and should be representative of the general popula-
tion. The initial requirement was a sampling frame, which
could be used to locate members of the target population. As
access to raw census data is limited to the Central Statistics
Office, two options were available: the use of quota sampling
or use of the Electoral Register. For scientific purposes, quota
sampling was considered unsuitable as the sample derived is
not based on any probabilistic mechanism and there is an
unknown degree of bias. The chosen option was to conduct
random sampling based on the Electoral Register. The regis-
ter has been found to be acceptable for population estimation
and for use as a sampling frame, having relatively stable entry
and exit patterns, with a low level of bias.21 The RANSAM
method used random, multistage sampling and most impor-
tantly ensured that every elector had an equal probability of
selection.
The sample of respondents was deemed to be moderately
representative of the general population. Our results showed
evidence of validity and internal consistency for the SF-36 in
this sample, corresponding with findings in other popula-
tions.8,11,12,14 The use of the SF-36 in mail administration has
previously been validated.24,25 Here the mail survey yielded a
response rate of 37% which is undoubtedly low, but this
exceeded expectations. No follow-up was conducted since the
target sample size was met and responses were received from
all primary sampling units. Such a low response rate might
however confer bias to the results, as the health status of non-
responders is unknown.26
There were no significant differences in scores for the sexes
in this sample, although elderly females reported better phys-
ical function, role physical and social function scores than
males. These results contrast with the findings of Jenkinson et
al, who reported that women had poorer health scores than
men in all but the general health dimension.12 This earlier
study involved a greater number of respondents, but the pro-
portion of males (45%) to females (55%) was similar to that in
our sample. There was no evidence to suggest that there were
significant differences between the health status of the Irish
and US populations based on the physical and mental health
summary scales.
In practice the instrument has several advantages, including
brevity and flexibility of administration methods. Standard
criteria for scoring and transforming the raw responses ensure
accurate group comparisons and it has been found suitable for
use in a wide variety of populations.12-14,16 The popularity of the
SF-36 continues to grow with the International Quality of
Life Assessment project, which has been translating, validating
and standardising the SF-36 for use in international studies
since 1991.27
In summary, these data present values for the SF-36 health
survey for a representative random sample of the Irish popu-
lation aged 18 years and over. The SF-36 was shown to have
acceptable internal consistency and validity and can be con-
sidered a suitable instrument for assessing health status and
quality of life in the Irish population.
Acknowledgements
This study was supported by the Irish Kidney Association
and The National Rehabilitation Board.

198 Irish Journal of Medical Science • Volume 169 • Number 3

 The Short Form 36 (SF-36) Health Survey: normative data for the Irish population

Appendix A: SF-36 Normative data, Ireland: scores for males in age bands
Age PF RP BP GH VT SF RE MH PCS MCS

18-24 years Median 100 100 92 87.5 75 100 100 84 56.71 54.64
(n=12) Range 55-100 0-100 22-100 30-100 50-90 37.5-100 3.33-100 56-100 37.05-60.23 38.39-59.49
Mean 95.42 90 91 82.25 82.67 72.50 89.58 88.89 82.18 54.34 52.63
Sd 12.87 30.15 24.64 19.33 13.40 18.34 25.95 14.35 6.94 7.97

25-34 years Median 95 100 100 77 75 93.75 100 84 54.90 53.08

(n=20) Range 60-100 50-100 41-100 52-97 50-95 37.5-100 0-100 44-100 40.40-68.99 25.18-61.23
Mean 90.53 92.11 85.85 77.17 73.42 88.47 84.21 79.37 53.37 51.94
Sd 12.90 16.78 18.90 14.28 11.43 16.68 30.16 15.22 6.05 9.13

35-44 years Median 95 100 92 81 70 100 100 80 55.24 54.14

(n=30) Range 20-100 0-100 31-100 37-100 20-100 25-100 0-100 48-100 26.83-61.96 26.02-62.14
Mean 87.93 89.17 83.67 76.83 65.33 88.75 78.89 77.47 53.02 50.51
Sd 19.39 26.82 20.79 15.11 22.63 21.36 33.31 15.02 7.40 10.60

45-54 years Median 90 100 74 77 67.5 100 100 80 50.90 55.29

(n=19) Range 25-100 0-100 12-100 35-100 30-100 0-100 0-100 36-100 24.51-58.68 20.61-63.22
Mean 83.89 81.94 73.32 73.88 66.39 85.53 92.59 78.89 47.94 52.89
Sd 19.2 33.00 24.24 16.56 22.28 27.72 24.40 14.38 10.01 9.58

55-64 years Median 90 100 100 74.50 75 100 100 90 52.27 56.15
(n=25) Range 15-100 0-100 22-100 25-100 35-95 25-100 0-100 48-100 20.72-55.77 34.70-62.81
Mean 84.13 82.29 80.20 70.00 67.29 86.00 87.50 83.17 49.33 53.69
Sd 18.50 31.69 27.08 23.33 18.36 23.47 23.70 15.33 9.52 8.08

65-74 years Median 70 75 74 67 62.5 87.5 100 78 45.89 57.43

(n=11) Range 0-100 0-100 31-100 20-92 30-95 25-100 33.33-100 60-100 18.72-51.92 47.02-67.51
Mean 56.36 62.50 71.82 60.67 62.00 72.73 92.59 80.80 40.72 56.77
Sd 35.78 40.09 27.58 20.46 24.06 30.53 22.22 15.06 11.99 8.97

75 years + Median 52.5 50 62.5 67 65 62.5 100 78 41.13 55.42

(n=12) Range 0-95 0-100 12-100 30-85 15-100 25-100 0-100 52-100 22.51-55.09 36.99-64.26
Mean 49.00 47.50 63.83 64.38 57.50 63.64 81.48 76.00 40.31 54.03
Sd 32.64 46.32 33.37 17.37 27.31 36.42 33.79 18.57 11.86 9.45

Appendix B: SF-36 Normative data, Ireland: scores for females in age bands
Age PF RP BP GH VT SF RE MH PCS MCS

18-24 years Median 95 100 92 78.5 70 93.75 100 76 54.84 51.63

(n=22) Range 60-100 0-100 41-100 25-100 30-95 50-100 0-100 32-100 34.72-63.27 24.33-61.60
Mean 92.50 88.64 81.64 77.14 64.55 84.66 74.24 78.00 53.76 49.08
Sd 9.61 29.61 22.36 18.80 19.08 18.07 36.99 17.96 7.49 10.85

25-34 years Median 95 100 84 86 70 100 100 80 54.36 53.62

(n=33) Range 35-100 0-100 12-100 5-100 10-100 25-100 0-100 16-100 19.04-60.73 15.37-62.14
Mean 85.31 71.88 73.09 73.63 62.81 81.25 79.17 74.63 49.20 49.57
Sd 22.32 42.00 28.71 27.91 23.00 24.80 39.49 19.32 11.98 11.58

35-44 years Median 95 100 84 79.5 65 87.5 100 80 53.94 52.56

(n=43) Range 20-100 0-100 0-100 5-100 20-85 37.5-100 0-100 32-96 13.28-59.56 26.69-61.00
Mean 87.74 81.40 75.70 74.05 61.05 82.85 86.05 74.38 50.43 50.27
Sd 18.94 33.23 26.82 21.87 19.75 18.71 22.39 16.69 10.30 9.05

45-54 years Median 90 100 100 77 67.5 100 100 80 55.33 53.35
(n=32) Range 15-100 0-100 10-100 12-100 0-95 25-100 0-100 44-100 20.02-67.89 26.93-63.08
Mean 86.72 83.06 80.28 73.61 64.53 85.16 87.10 76.25 51.07 50.93
Sd 19.58 33.78 28.41 23.76 20.09 21.17 31.83 15.34 11.44 8.64

55-64 years Median 85 100 92 79.5 72.5 100 100 88 53.24 55.90
(n=18) Range 20-100 0-100 0-100 35-100 0-90 12.5-100 0-100 36-100 30.31-60.10 39.97-65.21
Mean 78.06 76.39 78.94 76.94 63.61 87.50 75.93 79.33 50.20 53.03
Sd 21.70 37.84 28.75 17.39 22.67 21.86 39.28 18.87 8.86 8.50

65-74 years Median 80 100 62 62 65 100 100 84 47.07 58.02

(n=10) Range 45-100 0-100 31-100 42-100 45-95 50-100 66.66-100 64-100 24.28-52.00 52.59-67.27
Mean 72.22 86.11 66.40 70.11 67.22 91.25 96.30 83.50 44.74 58.49
Sd 20.17 33.33 26.59 17.77 14.17 16.72 11.11 11.80 8.69 5.37

75 years + Median 65 75 100 77 60 100 50 88 47.74 54.57

(n=8) Range 0-95 0-100 21-100 10-100 30-100 0-100 0-100 40-100 19.72-56.95 30.56-62.64
Mean 54.29 53.57 74.63 65.43 60.71 78.13 50.00 77.71 41.12 50.50
Sd 34.57 44.32 36.43 32.76 27.30 36.44 45.95 24.10 15.95 12.97

Irish Journal of Medical Science • Volume 169 • Number 3 199

C Blake et al
Figure 2. SF-36 Normative data, Ireland: comparison of median
physical and mental health summary scales with US population, in 18-24 year and
over 75 year age groups
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Correspondence to: Catherine Blake, UCD School of
Physiotherapy, Mater Misericordiae Hospital, Eccles Street,
Dublin 7, Ireland.
Irish Journal of Medical Science • Volume 169 • Number 3