Validity of the Iranian Version of Health Utility Index Mark 3 Quality of Life Questionnaire

Document Type: Original Article


1 Professor of Educational Planning, Health Management and Economic Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

2 Master of Health Economics, Health Management and Economic Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

3 Associate Professor of Medical Education, Medical Education Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

4 Associate Professor, Department of Biostatistics and Epidemiology, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran


Background: The aim of this study was to standardize and develop the health utility index III (HUI3); quality of life questionnaire. This study was conducted for the first time in Iran.
Method: Forward-backward translation method was applied in order to translate the Canadian version into Persian. The final version was developed after modifications. Double stage cluster sampling and simple random sampling were respectively used for population and patients. A total of 511 healthy people in 15 regions of Esfahan/Iran and 51 patients suffering from cardiovascular disease completed the questionnaire. Cronbach's alpha and interclass correlation coefficient were used for testing the reliability of the questionnaire.
Results: The mean age of population was 32.8 ± 11.3 years and the mean age of patients was 48.8 ± 6.2 years. The assessment of Interclass Correlation Coefficient of the tool in patients after two weeks in all eight questions ranged from 0.76 to 1 (ICC=0/91) that shows its high reliability. In addition, the average score in Alfa Cronbach was 0.68. Content validity of the questionnaire was 0.82. Differentiability of the test shows that a higher quality of life can be affected by male gender, higher education, low age, and employment In addition, the utility result of quality of life indicates a significant difference in the quality of life of patients compared with the general population (p = 0.004)
Conclusion: The results showed a translated version is valid, reliable and applicable in medical sciences studies and can be used to Persian language.


  1. Furlong W, Feeny D, Torrance G, Barr R, Horsman J. Guide to Design and Development of Health-State Utility Instrumentation. Centre for Health Economics and Policy Analysis (CHEPA). Hamilton, Canada: McMaster University. Centre for Health Economics and Policy Analysis; 1992.
  2. Fayers PM, Hays R. Assessing Quality of Life in Clinical Trials: Methods and Practice. USA: Oxford University Press; 2005.
  3. Mohammadbeigi A, Mohammadsalehi N, Aligol M. Validity and reliability of the instruments and types of measurments in health applied researches. J Rafsanjan Unive Med Sci 2015; 13(12):1153-70. Persian
  4. World Health Organization(WHO). Women's And Children's Health: Evidence of Impact of Human Rights; 2013. [cited 2015 Dec 16]. Available from:
  5. Nejat S, Montazeri A, Holakouie Naieni K, Mohammad K, Majdzadeh S. The World Health Organization quality of Life (WHOQOL-BREF) questionnaire: Translation and validation study of the Iranian version. J Sch Public Health Inst Public Health Res 2006; 4(4):1-12. Persian
  6. Noel CW, Lee DJ, Kong Q, Xu W, Simpson C, Brown D, et al. Comparison of Health State Utility Measures in Patients With Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2015;141(8):696-703.
  7. Reilly MC, Gooch KL, Wong RL, Kupper H, van der Heijde D. Validity, reliability and responsiveness of the Work Productivity and Activity Impairment Questionnaire in ankylosing spondylitis. Rheumatology (Oxford) 2010;49(4):812-9.
  8. Keren R, Pati S, Feudtner C. The Generation Gap. Pharmacoeconomics 2004;22(2):71-81.
  9. Luo N, Wang Q, Feeny D, Chen G, Li SC, Thumboo J. Measuring health preferences for Health Utilities Index Mark 3 health states: a study of feasibility and preference differences among ethnic groups in Singapore. Med Decis Making 2007;27(1):61-70.
  10. Marra CA, Esdaile JM, Guh D, Kopec JA, Brazier JE, Koehler BE, et al. A comparison of four indirect methods of assessing utility values in rheumatoid arthritis. Med Care 2004;42(11):1125-31.
  11. Marra CA, Esdaile JM, Guh D, Kopec JA, Brazier JE, Koehler BE, et al. A comparison of four indirect methods of assessing utility values in rheumatoid arthritis. Med Care 2004;42(11):1125-31.
  12. Pressler SJ, Eckert GJ, Morrison GC, Murray MD, Oldridge NB. Evaluation of the Health Utilities Index Mark-3 in heart failure. J Card Fail 2011;17(2):143-50.
  13. Furlong WJ, Feeny DH, Torrance GW, Barr RD. The Health Utilities Index (HUI) system for assessing health-related quality of life in clinical studies. Ann Med 2001;33(5):375-84.
  14. Grootendorst P, Feeny D, Furlong W. Health Utilities Index Mark 3: evidence of construct validity for stroke and arthritis in a population health survey. Med Care 2000;38(3):290-9.
  15. Cox CL, Lensing S, Rai SN, Hinds P, Burghen E, Pui CH. Proxy assessment of quality of life in pediatric clinical trials: application of the Health Utilities Index 3. Qual Life Res 2005;14(4):1045-56.
  16. Costet N, Le Gales C, Buron C, Kinkor F, Mesbah M, Chwalow J, et al. French cross-cultural adaptation of the Health Utilities Indexes Mark 2 (HUI2) and 3 (HUI3) classification systems. Clinical and Economic Working Groups. Qual Life Res 1998;7(3):245-56.
  17. Garster NC, Palta M, Sweitzer NK, Kaplan RM, Fryback DG. Measuring health-related quality of life in population-based studies of coronary heart disease: comparing six generic indexes and a disease-specific proxy score. Qual Life Res 2009;18(9):1239-47.
  18. Feeny D, Furlong W, Torrance GW, Goldsmith CH, Zhu Z, DePauw S, et al. Multiattribute and single-attribute utility functions for the health utilities index mark 3 system. Med Care 2002;40(2):113-28.
  19. Grant JS, Davis LL. Selection and use of content experts for instrument development. Res Nurs Health 1997;20(3):269-74.
  20. Rubio DM, Berg-Weger M, Tebb SS, Lee ES, Rauch S. Objectifying content validity: Conducting a content validity study in social work research. Social Work Research 2003; 27(2):94-104.
  21. Zamanzadeh V, Ghahramanian A, Rassouli M, Abbaszadeh A, Alavi-Majd H, Nikanfar AR. Design and Implementation Content Validity Study: Development of an instrument for measuring Patient-Centered Communication. J Caring Sci 2015;4(2):165-78.
  22. Lawshe CH. A quantitative approach to content validity1. Personnel Psychology 1975; 28(4):563-75.
  23. Zamanzadeh V, Rassouli M, Abbaszadeh A, Alavi-Majd H, Nikanfar AR, Ghahramanian A. Details of content validity and objectifying it in instrument development. Nursing Practice Today 2014; 1(3):163-71. Persian
  24. Group TW. The World Health Organization Quality of Life Assessment (WHOQOL): development and general psychometric properties. Soc Sci Med 1998;46(12):1569-85.
  25. Harkness JA, Schoua-Glusberg A. Questionnaires in translation. ZUMA-Nachrichten Spezial 1998; 3(1):87-127.
  26. Drummond MF, Sculpher MJ, Torrance GW, O'Brien BJ, Stoddart GL. Methods for the Economic Evaluation of Health Care Programmes. 3th ed. NewYork: Oxford University Press; 2005.
  27. Feeny D, Furlong W, Boyle M, Torrance GW. Multi-attribute health status classification systems. Health Utilities Index. Pharmacoeconomics 1995;7(6):490-502.
  28. Nikfar S, Kebriaeezadeh A, Dinarvand R, Abdollahi M, Sahraian MA, Henry D, et al. Cost-effectiveness of different interferon beta products for relapsing-remitting and secondary progressive multiple sclerosis: Decision analysis based on long-term clinical data and switchable treatments. Daru 2013;21(1):50.
  29. Deogan CL, Bocangel MK, Wamala SP, Månsdotter AM. A cost-effectiveness analysis of the Chlamydia Monday--a community-based intervention to decrease the prevalence of chlamydia in Sweden. Scand J Public Health 2010;38(2):141-50.
  30. Poku E, Brazier J, Carlton J, Ferreira A. Health state utilities in patients with diabetic retinopathy, diabetic macular oedema and age-related macular degeneration: a systematic review. BMC Ophthalmol 2013;13:74.
  31. Kaplan RM, Tally S, Hays RD, Feeny D, Ganiats TG, Palta M, et al. Five preference-based indexes in cataract and heart failure patients were not equally responsive to change. J Clin Epidemiol 2011;64(5):497-506.
  32. Tavakol M, Dennick R. Making sense of Cronbach's alpha. Int J Med Educ 2011; 2: 53–5.
  33. Boran P, Horsman J, Tokuc G, Furlong W, Muradoglu PU, Vagas E. Translation and cultural adaptation of health utilities index with application to pediatric oncology patients during neutropenia and recovery in Turkey. Pediatr Blood Cancer 2011;56(5):812-7.
  34. Eldridge SM, Ukoumunne OC, Carlin JB. The intra‐cluster correlation coefficient in cluster randomized trials: a review of definitions. International Statistical Review 2009; 77(3):378-94.
  35. Yang YJ, Tsai LS, Wu YH, Hsieh YW, Hsieh CL, Howe TH. The Competence of Fieldwork Students in Administering the Barthel Index. Hong Kong Journal of Occupational Therapy 2008;18(1):28-33.
  36. Baranov A, Albitskiy V, Vinyarskaya I, Chernikov V, Ustinova N, Simonova O, et al. Creation and validation of the Russian version of the questionnaire for the assessment of utility indexes in pediatric practice. New Medical Technologies 2012;9(1).
  37. Boyle MH, Furlong W, Feeny D, Torrance GW, Hatcher J. Reliability of the Health Utilities Index--Mark III used in the 1991 cycle 6 Canadian General Social Survey Health Questionnaire. Qual Life Res 1995;4(3):249-57.
  38. Stolk EA, Busschbach JJV. A comparison of the EuroQol and the Health Utilities Index in patients treated for congenital anomalies. The European Journal of Health Economics (HEPAC) 2001;2(2):54-9.
  39. Coons SJ, Rao S, Keininger DL, Hays RD. A comparative review of generic quality-of-life instruments. Pharmacoeconomics 2000;17(1):13-35.
  40. Cheng AK, Rubin HR, Powe NR, Mellon NK, Francis HW, Niparko JK.. Cost-utility analysis of the cochlear implant in children. JAMA 2000;284(7):850-6.
  41. Wee HL, Machin D, Loke WC, Li SC, Cheung YB, Luo N, et al. Assessing differences in utility scores: a comparison of four widely used preference-based instruments.. Value Health 2007;10(4):256-65.
  42. Sung L, Greenberg ML, Doyle JJ, Young NL, Ingber S, Rubenstein J, et al. Construct validation of the Health Utilities Index and the Child Health Questionnaire in children undergoing cancer chemotherapy. Br J Cancer 2003; 88(8): 1185–90.
  43. Lee JM, Rhee K, O'grady MJ, Basu A, Winn A, John P, et al. Health utilities for children and adults with type 1 diabetes. Med Care 2011;49(10):924-31.
  44. Philipsson A, Duberg A, Möller M, Hagberg L. Cost-utility analysis of a dance intervention for adolescent girls with internalizing problems. Cost Eff Resour Alloc 2013;11(1):4.
  45. Nejat S. Quality of Life and its Measurement. Iranian Journal of Epidemiology Iranian Journal of Epidemiology 2008; 4 (2):57-62. Persian.