Does EQ-5D work in China? Exploring cultural differences in measuring health

Health-related quality of life (HRQoL) has become an essential aspect of measuring health. Most of the commonly used generic HRQoL measures were developed in Europe or North America and have been translated into other languages for use worldwide. Arguably, this adaption process assumes that health, as a concept, has universal cultural equivalence. The aim of this thesis is to explore cultural differences in defining and measuring health, by focusing on the adaption of EQ-5D, which is a widely used Western HRQoL measure, for use in China, given vast cultural differences between China and Western countries. A series of studies were conducted to attain this aim. A scoping review identified generic HRQoL measures that were developed for Chinese populations and established a preliminary conceptual framework of health to summarise health dimensions that are important in assessing health in a Chinese cultural setting. This work was followed by a qualitative study that investigated how Chinese lay people describe and appraise health to justify the preliminary framework and to identify additional health dimensions. A Q-methodological investigation and a multidimensional unfolding analysis were subsequently undertaken to establish the relative importance of these health dimensions in a diverse range of Chinese participants. The studies identified several health dimensions, such as “spirit (Shen)”, “body constitution” and “sleep”, which were highlighted in the Chinese literature and by Chinese lay participants, but have not been commonly covered in Western HRQoL measures such as EQ-5D. The results demonstrate that health is a culturally grounded concept and, due to cultural differences, it cannot be taken for granted that a well recognised Western HRQoL measure is always appropriate for use in other cultural contexts. Careful consideration and testing of conceptual equivalence is essential when deciding whether to use an existing HRQoL measure outside of the culture in which it was developed.