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SUMMARY The need to find accurate and reliable indicators on which to base the planning, provision, and evaluation of health services gave impetus to the attempt to develop reliable and valid measures of the perceived health status of the consumers of health care. Subjective measures can provide an important complement to traditional statistics by giving direct access to the personal feelings of discomfort or distress that influence the use of health services. Such measures also give meaningful criteria for the evaluation of the efficacy of such services. Self assessments of health obtained from surveys and interviews have consistently found age and sex differences in the tendency to report symptoms, ill-health, disability, visits to doctors, and sickness absence. Many of these data, however, may have been misleading in using instruments of unknown or uncertain validity and reliability. Nevertheless, subjective assessments of health have been shown to have value and to add a dimension to objective measurements of health. They have been considered to be one of the better predictors of mortality and of adjustment to major episodes of illness. Effects of sex on healthIn most countries women outlive men; in Western countries there has been an increase in excess male mortality7 and men have an excess of more serious episodes of illness and make more successful suicide attempts. Men also appear to engage in more "risky" behaviours-smoking, drinking alcohol, and driving are more common in men than women-whereas women are more likely to engage in "preventive" behaviours such as going for screening and immunisation, although they do take more prescribed drugs. Nevertheless, women report more symptoms of both mental and physical illness and utilise services more than men. These rates may be inflated by differences in illness behaviour, physician expections, and men's reluctance to report emotional problems.710Several studies have tried to relate sex differences in perceived health to differential employment and status. Results of such studies have been contradictory. Employment status has been found to 156

Patient-completed health status instruments currently available for use with rheumatoid arthritis (RA) patients lack adequate reliability and responsiveness, making them unsuitable for use as outcome measures in clinical trials. A search of the literature failed to identify a quality of life (QoL) instrument specific to RA. The present study was designed to be the first stage in the development of such a measure. Qualitative interviews were held with 50 RA patients, 25 in the UK and 25 in The Netherlands. The interviews indicated that RA has a detrimental effect on many areas of life, including moods and emotions, social life, hobbies, everyday tasks, personal and social relationships, and physical contact. Transcripts of the interviews formed the source of items for the RAQoL, the first RA-specific QoL instrument.

It is concluded that the L-QoL should prove a valuable instrument for assessing patient-based outcome in clinical trials and practice.

The Nottingham Health Profile is a two-part, self-administered questionnaire designed to provide a simple and standardised measure of perceived health problems, physical, social, and mental. It was developed in order to supply a tool for the survey of populations, but has also proved to be of value in clinical situations as a valid means of assessing the wider impact of illness on the daily life of patients.Part I consists of 38 statements with weighted scores in the areas of pain, physical mobility, sleep, energy, social isolation, and emotional reactions, to which the respondent is required to answer yes or no. The development of this part of the profile has been described in previous papers.1" Part II is designed to give a general estimate of those areas of social function perceived to be affected by the health problems of the individual. This part contains a single statement on each of the following areas: paid employment, jobs around the home, social life, sex life, family relationships, hobbies/interests, and holidays. RELIABILITYOne of the requirements of a standardised measure is that it should be reliable. Scores should show consistency over time and there should be some numerical estimate of the degree of consistency exhibited by the instrument.The reliability of a set of scores can logically be defined as the proportion of the measured variance which is the 'true' variance, that is, the genuine value 297 of whatever is being measured. The remainder will be error variance composed of elements which, it is usually assumed, will occur independently and at random. In practice this assumption may be unfounded, for example, where the initial administration of a test sensitises the respondents to the content and affects subsequent administrations of that test. There are three well-established methods for estimating reliability:(1) The method of internal consistency where items on an instrument are divided into two equivalent parts-the split half technique-and the correlations between the scores on each part are computed.(2) Alternate forms, where two instruments which have been developed in parallel and which measure the same attribute are administered and the scores on one form are correlated with the scores on the other.(3) The test re-test technique, where the same test is administered on two separate occasions to the same group of individuals and the correlation between the two sets of scores is computed.The first method requires that the items in the instrument should be homogeneous with respect to the attribute being measured and the second method requires that a parallel form of the instrument should exist. Neither of these requirements are fulfilled in the case of the Nottingham Health Profile. The third method, test re-test, is thus the preferred one.5