Quality of Life Concepts

Secondary Health Conditions

Short-Form Health Survey 36 (SF-36)

Description: A generic health status measure (health-related quality of life [QoL]) designed to be applied to all health conditions and to assess general health concepts, such as functional status and well-being [1].

Format: 36 items covering eight domains: physical functioning, role limitations due to physical health problems, bodily pain, general health, vitality, social functioning, role limitations due to emotional problems and mental health.

Scoring: The scoring is norm-based, with a general population mean score of 50 and a standard deviation of 10. Higher scores indicate higher levels of health. There is published data and norms available for most health conditions as well as for the general population (in Canada and USA).

In addition, the SF-36 can be scored to produce a preference-based single index measure for health from these data using general population values (SF-6D). The SF-6D allows the analyst to obtain quality adjusted life years (QALYs) from the SF-36 for use in cost utility analysis.  The scoring for the SF-6D can be obtained at: http://www.shef.ac.uk/scharr/sections/heds/mvh/sf-6d.

Administration and Burden: Interviewer-administered; Self-administered. Approximately 5-10 minutes.

Psychometrics for SCI: The SF-36 has acceptable psychometric properties in both the physical and mental components for use in the SCI population with some limitations [2].

Language(s): Translated for use in more than 40 other countries.

QoL Concept: The SF-36 is a measure of Health-Related QoL, which corresponds to Boxes B (societal standards and priorities) and C (achievements; health-related QoL) of Dijker’s Model

If the SF-6D scoring algorithm is used, then the SF-36 produces a Utility outcome, which corresponds to Boxes A (objective evaluations; quality adjusted life years), B (societal standards and priorities) and C (achievements; health-related QoL) of Dijker’s Model.

Permissions/Where to Obtain: Copyrighted; The SF-36 can be purchased at the SF-36 website at: http://www.sf-36.org/.


  1. Ware JEJ, Kosinski M, Gandek B. SF-36 health survey: manual and interpretation guide. Lincoln: Quality Metric; 2001.

  2. Ku JH. Health-related quality of life in patients with spinal cord injury: review of the short form 36-health questionnaire survey. Yonsei Med J 2007; 30;48:360-70.


Pressure Ulcer SCI Studies: One cross-sectional observational study:

1. Westgren N, Levi R. Quality of life and traumatic spinal cord injury. Arch Phys Med Rehabil 1998; 79:1433-9.

Sensitivity to Impact: Westgren and Levi (1998) examined the impact of secondary health conditions on health-related quality of life (QoL) using the Sort-Form 36 (SF-36) in a sample of community-dwelling persons with spinal cord injury (SCI; N = 320) living in Sweden.  With regard to pressure ulcers, they found that the physical functioning and social functioning sub-scales were negatively impacted.

Suggestions for Use: The SF-36 appears to be sensitive to the impact of pressure ulcers after SCI but further work is required to conclusively demonstrate this.  There are a number of advantages and disadvantages associated with the SF-36 that should be considered.

The SF-36 and its derivative (SF-12) are the most widely used measures of health status, which allows for the evaluation of various patient populations.  As such, the SF-36 has been used widely in the SCI literature as well.  However, there is some controversy regarding this measure of health-related QoL, which are not well-suited (items related to walking) or even seen as demeaning to persons with SCI.  There are also reported floor and ceiling effects.  For a full review of the issues associated with the SF-36, refer to Hays et al. [1]) and/or Andresen et al. [2]. 

Despite these controversies and problems, the limitations of the SF-36 may be minimized by using it in conjunction with condition-specific tools.  As well, the SF-36 been endorsed by the Spinal Cord Outcomes Partnership Endeavor’ (SCOPE) [3], which is a broad-based international consortium of scientists and clinical researchers representing academic institutions, industry, government agencies, not-for-profit organizations and foundations has endorsed the SF-36, although not specifically to assess the impact of pressure ulcers.

Additional References:

  1. Hays RD, Hahn H, Marshall G. Use of the SF-36 and other health-related quality of life measures to assess persons with disabilities. Arch Phys Med Rehabil 2002;83:S4-S9.

  2. Andresen EM, Fouts BS, Romeis JC, Brownson CA. Performance of health-related quality-of-life instruments in a spinal cord injured population. Arch Phys Med Rehabil 1999;80:877-84.

  3. Alexander MS, et al. Outcome measures in spinal cord injury: Recent assessments and recommendations for future directions. Spinal Cord 2009:1-10.

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