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.