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Anchoring vignettes for health comparisons: an analysis of response consistency

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Abstract

Purpose

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.

Method

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.

Results

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.

Conclusion

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.

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Notes

  1. We focus on the issue of DIF in cross-population comparisons, but we note that it is also possible for DIF to occur within individuals, for example if patients change their point of reference over time when rating their own health [30].

  2. A second key assumption is Vignette equivalence—that each vignette is perceived by all respondents as the same underlying level.

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Acknowledgments

This research was funded by an Australian Research Council Discovery Project Grant (DP110101426). We would like to thank our colleagues in the Centre for Health Economics for allowing us to pilot early versions of the survey. Kathryn Kolo and Aimee Maxwell were indispensable in their support of the online survey. None of this research would be possible without the time and input of the interview and online participants. Ethical approval was granted by the University Human Research Ethics Committee.

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Authors and Affiliations

  1. Centre for Health Economics, Monash University, Building 75, Clayton, VIC, 3800, Australia

    Nicole Au & Paula K. Lorgelly

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Corresponding author

Correspondence to Nicole Au.

Appendices

Appendix 1

We identified suitable vignettes for the five separate dimensions of the EQ-5D-5L (mobility, self-care, usual activities, pain/discomfort, anxiety/depression) using existing vignettes from the English Longitudinal Study of Ageing (ELSA) [47], Survey of Health, Ageing and Retirement in Europe (SHARE) [48] and an online vignette library (http://gking.harvard.edu/vign) as a guide. Each health dimension (EQ-5D domain) was assigned three vignettes, representing different levels of severity. We constructed two versions of vignettes (A and B), which were randomised across participants (see ‘Appendix 2’). In version A, participants were shown a total of 15 vignettes (5 dimensions × 3 levels of severity) and asked to rate the corresponding health dimension of the 15 hypothetical individuals. Vignettes were shown sequentially by dimension, but within each dimension, the severity of the vignettes was randomly ordered. Box 1 provides an example of a mobility dimension vignette in version A.

Box 1 An example vignette and assessment question for mobility in version A
Full size table

For version B of the vignettes, we constructed overall health state descriptions that included information on all five health dimensions. This was undertaken to more closely imitate the breadth of information that an individual has about their own health when completing the EQ-5D-5L. The randomisation across the two versions allowed us to explore whether or not participants are more likely to rate themselves and the vignettes on the same underlying scale when information on other health dimensions is included in the vignette. The five separate vignettes for each dimension from version A were combined at each level of severity to form three health state vignettes of hypothetical people in health states of low, moderate and severe health problems. An example of a health state description from version B is given in Box 2.

Box 2 An example of the vignette text in version B
Full size table

Following each health state description in version B, participants were asked to rate the health of hypothetical individuals using three measures: general SRH, the EQ-5D-5L and the EQ-VAS. There are a number of key differences between the two versions. First, the vignettes provided in version B, although fewer in number, are substantially longer and more complex than in version A. Second, the vignettes in version B provide additional information about other aspects of the health of the hypothetical individual, which may influence how respondents rate the separate dimensions of the EQ-5D-5L for the vignettes. Third, the description of multiple dimensions in version B enables respondents to answer a general health question and the EQ-VAS for the hypothetical individuals; these are not possible following the single dimension vignettes in version A.

In both versions of the survey, participants first rated the health of the hypothetical individuals and then their own health using a general self-assessed health question, the EQ-5D-5L and the EQ-VAS. The vignettes were asked before the self-ratings as vignettes have been shown to act as a ‘primer’ to help with response consistency [49]. At the beginning of the vignette task, participants were instructed to assume that the people in the vignettes were of the same age and background as themselves; this is to encourage response consistency. To further aid response consistency, we developed gender-specific surveys, such that female (male) participants rated the health of hypothetical females (males) only. To avoid any suggestion that the individuals in the vignettes were of a particular age [50], we selected common names which repeatedly featured in the top 100 names of the decade since 1950.

Appendix 2

Instruction on the screen preceding the vignette assessment task:

We will now give you some examples of persons in different states of health. We would like to know how you evaluate the health of these persons. Please assume that the persons have the same age and background that you have.

Vignettes: version A

Mobility

  • [Karen] walks for one to two kilometres everyday without tiring, but [she] cannot run anymore due to an injured knee.

  • [Vicky] has a lot of swelling in [her] legs, and walking around more than 50 m is an effort as [her] legs feel heavy.

  • [Rebecca] is able to walk distances of up to 200 m without any problems but feels tired after walking 1 km or climbing up more than one flight of stairs.

Self-care

  • [Julie] can wash [her] face and comb [her] hair, but cannot wash [her] whole body without help. [She] needs assistance with putting clothes on over [her] head, but can put garments on the lower half of [her] body.

  • [Sarah] keeps [herself] neat and tidy. [She] showers and dresses [herself] each morning in under 15 min.

  • [Teres] takes twice as long as others to put on and take off clothes, but needs no help with this. [She] is able to bathe and groom [herself], but it requires effort, so on some days, [she] does not bathe.

Usual activities (e.g. work, study, housework, family or leisure activities)

  • [Nancy] works in the public sector. [She] misses work 1 or 2 days per year due to illness. [She] has a headache once a month that is usually relieved 1 h after taking a pill.

  • [Helen] is a teacher and misses work 1–2 days per month due to illness. [She] sometimes feels tired and exhausted when [she] stands for long periods in the classroom. On these occasions, [she] makes some mistakes in correcting homework and exams.

  • [Carol] lives on [her] own and has had stomach problems for the past 2 weeks. [She] has not cleaned the house in 3 weeks, has stopped cooking and needs someone to do the shopping for [her].

Pain/discomfort

  • [Emily] has back pain that makes changes in body position very uncomfortable. [She] is unable to stand or sit for more than half an hour. Medicines decrease the pain a little, but it is there all the time.

  • [Lisa] suffers from arthritis that causes stiffness and occasional pain in [her] wrists and hands. Her symptoms are relieved with low doses of medication.

  • [Amy] has a headache once a month that is usually relieved 1 h after taking a pill.

Anxiety/depression

  • [Patricia] feels happy and enjoys things like hobbies or social activities around half of the time. Otherwise [she] worries about the future and feels depressed a couple of days a month.

  • [Michelle] remains happy and cheerful most of the time, but once a week feels worried about things at work. [She] feels very sad once a year but is able to come out of this mood within a few hours.

  • [Deborah] feels tense and on edge all the time. [She] is depressed nearly everyday and feels hopeless. [She] also has a low self-esteem, is unable to enjoy life and feels that [she] has become a burden.

Vignettes: version B

  • [Brian] walks for one to 3 km everyday without tiring, but [he] cannot run anymore due to an injured knee. [He] keeps [himself] neat and tidy. [He] showers and dresses [himself] each morning in under 15 min. [He] works in the public sector. [He] misses work 1 or 2 days per year due to illness. [He] has a headache once a month that is relieved 1 h after taking a pill. [Brian] remains happy and cheerful most of the time, but once a week feels worried about things at work. [He] feels very sad once a year but is able to come out of this mood within a few hours.

  • [George] is able to walk distances of up to 200 m without any problems but feels tired after walking 1 km or climbing up more than one flight of stairs. [He] takes twice as long as others to put on and take off clothes, but needs no help with this. [He] is able to bathe and groom [himself], but it requires effort, so on some days [he] does not bathe. [He] is a teacher and misses work 1–2 days per month due to illness. [He] sometimes feels tired and exhausted when [he] stands for long periods in the classroom. On these occasions, [he] makes some mistakes in correcting homework and exams. [George] suffers from arthritis that causes stiffness and occasional pain in [his] wrists and hands. His symptoms are usually relieved with low doses of medication. [He] feels happy and enjoys things like hobbies or social activities around half of the time. Otherwise [he] worries about the future and feels depressed a couple of days a month.

  • [William] has a lot of swelling in [his] legs, and walking around more than 50 m is an effort as [his] legs feel heavy. [He] can wash [his] face and comb [his] hair, but cannot wash [his] whole body without help. [He] needs assistance with putting clothes on over [his] head, but can put garments on the lower half of [his] body. [He] lives on [his] own and has had a stomach problem for the past month. [He] has not cleaned the house in 3 weeks, has stopped cooking and needs someone to do the shopping for him. [William] has back pain that makes changes in body position very uncomfortable. [He] is unable to stand or sit for more than half an hour. Medicines decrease the pain a little, but it is there all the time. [He] feels tense and on edge all the time. [He] is depressed nearly everyday and feels hopeless. [He] also has a low self-esteem, is unable to enjoy life and feels that [he] has become a burden.

Response options for each health dimension:

Mobility

 [He] has no problems in walking about

□

 [He] has slight problems in walking about

□

 [He] has moderate problems in walking about

□

 [He] has severe problems in walking about

□

 [He] is unable to walk about

□

Self-care

 [He] has no problems washing or dressing [himself]

□

 [He] has slight problems washing or dressing [himself]

□

 [He] has moderate problems washing or dressing [himself]

□

 [He] has severe problems washing or dressing [himself]

□

 [He] is unable to wash or dress [himself]

□

Usual activities (e.g. work, study, housework, family or leisure activities)

 [He] has no problems doing [his] usual activities

□

 [He] has slight problems doing [his] usual activities

□

 [He] has moderate problems doing [his] usual activities

□

 [He] has severe problems doing [his] usual activities

□

 [He] is unable to do [his] usual activities

□

Pain/discomfort

 [He] has no pain or discomfort

□

 [He] has slight pain or discomfort

□

 [He] has moderate pain or discomfort

□

 [He] has severe pain or discomfort

□

 [He] has extreme pain or discomfort

□

Anxiety/depression

 [He] is not anxious or depressed

□

 [He] is slightly anxious or depressed

□

 [He] is moderately anxious or depressed

□

 [He] is severely anxious or depressed

□

 [He] is extremely anxious or depressed

□

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Au, N., Lorgelly, P.K. Anchoring vignettes for health comparisons: an analysis of response consistency. Qual Life Res 23, 1721–1731 (2014). https://doi.org/10.1007/s11136-013-0615-2

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