Are symbols useful and culturally acceptable in health-state valuation studies? An exploratory study in a multi-ethnic Asian population

BACKGROUND Symbols have been used in health state valuation studies to help subjects distinguish the severity of various characteristics of a given health state. Symbols used in such studies need to be evaluated for their cross-cultural appropriateness because a given symbol may have different meanings or acceptability in different cultures, which may affect results of such studies. OBJECTIVES To evaluate if using symbols to differentiate health states of different severity is useful and culturally acceptable in a multi-ethnic, urban Asian population. METHODS Using in-depth interviews with adult Chinese, Malay, and Indian Singaporeans conducted in English/mother-tongue, subjects were shown a health state with 6 levels (Health Utilities Index 3 vision), each displayed with a symbol, and asked (1a) if symbols were useful in differentiating severity of each level (measured using dichotomous and 0-10 visual analog scale [VAS] scales) or (1b) offensive and (2) to assess 7 alternative sets of symbols. RESULTS Of 63 subjects (91% response rate), 18 (29%) felt symbols were useful in differentiating severity of each level. Reported usefulness of symbols was fair (median VAS score: 3.0, score exceeding 5.0 for 33% of subjects). One Malay subject felt symbols were offensive. CONCLUSIONS Use of symbols for health state valuation was culturally acceptable and useful for some subjects.