Self-rated health (SRH) is widely used to measure and compare the health status of different groups of individuals. However, SRH can suffer from heterogeneity in reporting styles, making health comparisons problematic. Anchoring vignettes is a promising technique for improving inter-group comparisons of SRH. A key identifying assumption of the approach is response consistency—that respondents rate themselves using the same underlying response scale that they rate the vignettes. Despite growing research into response consistency, it remains unclear how respondents rate vignettes and why respondents may not assess vignettes and themselves consistently.
Vignettes for the EQ-5D-5L were developed and included in an online survey. In-depth interviews were conducted with participants following survey completion. Response consistency was examined through qualitative analysis of the interview responses and quantitative coding of participants’ thought processes.
Our analysis showed that anchoring vignettes for the EQ-5D-5L is feasible, but that response consistency may not hold for some participants. Respondents are more likely to rate their own health and vignettes in the same way if presented with overall health state vignettes than single health dimension vignettes, and if they imagined themselves in the health state of the hypothetical individual.
This research highlights opportunities to improve the design of anchoring vignettes in order to enhance response consistency. It additionally provides new evidence on the feasibility of employing anchoring vignettes for the EQ-5D-5L, which is promising for future work to address reporting heterogeneity in the EQ-5D-5L.
Idler, E. L., & Benyamini, Y. (1997). Self-rated health and mortality: A review of twenty-seven community studies.
Journal of Health and Social Behavior,38(1), 21–37.
Gold, M., Franks, P., & Erickson, P. (1996). Assessing the health of the nation: The predictive validity of a preference-based measure and self-rated health.
Medical Care,34(2), 163–177.
Clarke, P. M., Hayes, A. J., Glasziou, P. G., Scott, R., Simes, J., & Keech, A. C. (2009). Using the EQ-5D index score as a predictor of outcomes in patients with type 2 diabetes.
Medical Care,47(1), 61–68.
Rabin, R., & Charro, F. D. (2001). EQ-SD: A measure of health status from the EuroQol Group.
Annals of Medicine,33(5), 337–343.
McHorney, C. A. (1999). Health status assessment methods for adults: Past accomplishments and future challenges 1.
Annual Review of Public Health,20(1), 309–335.
Higginson, I. J., & Carr, A. J. (2001). Measuring quality of life: Using quality of life measures in the clinical setting.
British Medical Journal (BMJ),322(7297), 1297.
Garratt, A., Schmidt, L., Mackintosh, A., & Fitzpatrick, R. (2002). Quality of life measurement: Bibliographic study of patient assessed health outcome measures.
BMJ,324(7351), 1417. doi:
Devlin, N. J., Parkin, D., & Browne, J. (2010). Patient reported outcome measures in the NHS: New methods for analysing and reporting EQ 5D data.
Health Economics,19(8), 886–905.
van Doorslaer, E., & Koolman, X. (2004). Explaining the differences in income-related health inequalities across European countries.
Health Economics,13(7), 609–628. doi:
Euroqol Group. (1990). EuroQol-a new facility for the measurement of health-related quality of life.
Health Policy,16(3), 199–208.
Murray, C. J. L., Tandon, A., Salomon, J. A., Mathers, C. D., & Sadana, R. (2002). Cross-population comparability of evidence for health policy.
GPE Discussion Paper No. 46. Geneva: WHO/EIP.
Kaplan, G., & Baron-Epel, O. (2003). What lies behind the subjective evaluation of health status?
Social Science and Medicine,56(8), 1669–1676.
Andersen, M., & Lobel, M. (1995). Predictors of health self-appraisal: What’s involved in feeling healthy?
Basic and Applied Social Psychology,16(1–2), 121–136. doi:
Lindeboom, M., & Van Doorslaer, E. (2004). Cut-point shift and index shift in self-reported health.
Journal of Health Economics,23(6), 1083–1099.
Groot, W. (2000). Adaptation and scale of reference bias in self-assessments of quality of life.
Journal of health economics,19(3), 403–420.
Baron-Epel, O., Kaplan, G., Haviv-Messika, A., Tarabeia, J., Green, M. S., & Nitzan Kaluski, D. (2005). Self-reported health as a cultural health determinant in Arab and Jewish Israelis: MABAT—National Health and Nutrition Survey 1999–2001.
Social Science and Medicine,61(6), 1256–1266.
Wiseman, V. L. (1999). Culture, self-rated health and resource allocation decision-making.
Health Care Analysis,7(3), 207–223.
Kerkhofs, M., & Lindeboom, M. (1995). Subjective health measures and state dependent reporting errors.
Health Economics,4(3), 221–235.
Sadana, R., Mathers, C. D., Lopez, A. D., Murray, C. J. L., & Iburg, K. (2000). Comparative analyses of more than 50 household surveys on health status.
GPE Discussion Paper No. 15. Geneva: World Health Organization.
Shmueli, A. (2003). Socio-economic and demographic variation in health and in its measures: The issue of reporting heterogeneity.
Social Science and Medicine,57(1), 125–134.
Humphries, K. H., & Van Doorslaer, E. (2000). Income-related health inequality in Canada.
Social Science and Medicine,50(5), 663–671.
Jürges, H. (2007). True health vs response styles: Exploring cross-country differences in self-reported health.
Health Economics,16(2), 163–178. doi:
van Doorslaer, E., & Gerdtham, U.-G. (2003). Does inequality in self-assessed health predict inequality in survival by income? Evidence from Swedish data.
Social Science and Medicine,57(9), 1621–1629. doi:
Holland, P. W., & Wainer, H. (1993).
Differential item functioning. Hillsdale NJ: Lawrence Erlbaum.
King, G., Murray, C. J. L., Salomon, J. A., & Tandon, A. (2004). Enhancing the validity and cross-cultural comparability of measurement in survey research.
American Political Science Review,98(01), 191–207.
Shmueli, A. (2002). Reporting heterogeneity in the measurement of health and health-related quality of life.
Schwartz, C. E., & Finkelstein, J. A. (2009). Understanding inconsistencies in patient-reported outcomes after spine treatment: Response shift phenomena.
The Spine Journal,9(12), 1039–1045. doi:
Baker, M., Stabile, M., & Deri, C. (2004). What do self-reported, objective, measures of health measure?
Journal of Human Resources,39(4), 1067–1093.
Kapteyn, A., Smith, J. P., & Van Soest, A. (2007). Vignettes and self-reports of work disability in the United States and the Netherlands.
The American Economic Review,97(1), 461–473.
Kapteyn, A., Smith, J., & Van Soest, A. (2011). Are Americans really less happy with their incomes?
RAND Working Paper Series WR-
Grol-Prokopczyk, H., Freese, J., & Hauser, R. M. (2011). Using anchoring vignettes to assess group differences in general self-rated health.
Journal of Health and Social Behavior,52(2), 246.
Bago D’Uva, T., Van Doorslaer, E., Lindeboom, M., & O’Donnell, O. (2008). Does reporting heterogeneity bias the measurement of health disparities? [Article].
Health Economics,17(3), 351–375. doi:
Salomon, J. A., Tandon, A., & Murray, C. J. L. (2004). Comparability of self rated health: Cross sectional multi-country survey using anchoring vignettes.
British Medical Journal,328(7434), 258.
Datta Gupta, N., Kristensen, N., & Pozzoli, D. (2010). External validation of the use of vignettes in cross-country health studies.
Economic Modelling,27(4), 854–865. doi:
Bago d’Uva, T., Lindeboom, M., O’Donnell, O., & van Doorslaer, E. (2011). Slipping anchor? Testing the vignettes approach to identification and correction of reporting heterogeneity.
Journal of Human Resources,46(4), 875–906.
Van Soest, A., Delaney, L., Harmon, C., Kapteyn, A., & Smith, J. P. (2011). Validating the use of anchoring vignettes for the correction of response scale differences in subjective questions.
Journal of the Royal Statistical Society. Series A: Statistics in Society,174(3), 575–595.
König, H.-H., Bernert, S., Angermeyer, M. C., Matschinger, H., Martinez, M., Vilagut, G., et al. (2009). Comparison of population health status in six European countries: Results of a representative survey using the EQ-5D Questionnaire.
Medical Care,47(2), 255–261. doi:
Lubetkin, E., Jia, H., Franks, P., & Gold, M. (2005). Relationship among sociodemographic factors, clinical conditions, and health-related quality of life: Examining the EQ-5D in the U.S. general population.
Quality of Life Research,14(10), 2187–2196. doi:
Sun, S., Chen, J., Johannesson, M., Kind, P., Xu, L., Zhang, Y., et al. (2011). Population health status in China: EQ-5D results, by age, sex and socio-economic status, from the National Health Services Survey 2008.
Quality of Life Research,20(3), 309–320.
Maheswaran, H., Petrou, S., Rees, K., & Stranges, S. (2012). Estimating EQ-5D utility values for major health behavioural risk factors in England.
Journal of Epidemiology and Community Health,67(2), 172–180. doi:
Søltoft, F., Hammer, M., & Kragh, N. (2009). The association of body mass index and health-related quality of life in the general population: Data from the 2003 Health Survey of England.
Quality of Life Research,18(10), 1293–1299.
Burström, K., Johannesson, M., & Diderichsen, F. (2001). Swedish population health-related quality of life results using the EQ-5D.
Quality of Life Research,10(7), 621–635. doi:
Marmot, M., Banks, J., Blundell, R., Lessof, C., & Nazroo, J. (2003).
Health, wealth and lifestyles of the older population in England: ELSA 2002. London: Institute for Fiscal Studies.
Börsch-Supan, A., Hank, K., & Jürges, H. (2005). A new comprehensive and international view on ageing: Introducing the ‘Survey of Health, Ageing and Retirement in Europe’.
European Journal of Ageing,2(4), 245–253.
Jürges, H., & Winter, J. (2011). Are anchoring vignettes ratings sensitive to vignette age and sex?
Health Economics,22(1), 1–13. doi:
About this article
Anchoring vignettes for health comparisons: an analysis of response consistency
Nicole Au Paula K. Lorgelly
Springer International Publishing
Quality of Life Research
An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation - An Official Journal of the International Society of Quality of Life Research
Print ISSN: 0962-9343
Electronic ISSN: 1573-2649