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Open Access Research article

Exploring differential item functioning in the SF-36 by demographic, clinical, psychological and social factors in an osteoarthritis population

Beth Pollard1*, Marie Johnston1 and Diane Dixon2

Author Affiliations

1 Aberdeen Health Psychology Group, University of Aberdeen, 2nd Floor, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK

2 School of Psychological Sciences and Health, University of Strathclyde, Glasgow, UK

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BMC Musculoskeletal Disorders 2013, 14:346  doi:10.1186/1471-2474-14-346

Published: 11 December 2013



The SF-36 is a very commonly used generic measure of health outcome in osteoarthritis (OA). An important, but frequently overlooked, aspect of validating health outcome measures is to establish if items work in the same way across subgroup of a population. That is, if respondents have the same ‘true’ level of outcome, does the item give the same score in different subgroups or is it biased towards one subgroup or another. Differential item functioning (DIF) can identify items that may be biased for one group or another and has been applied to measuring patient reported outcomes. Items may show DIF for different conditions and between cultures, however the SF-36 has not been specifically examined in an osteoarthritis population nor in a UK population. Hence, the aim of the study was to apply the DIF method to the SF-36 for a UK OA population.


The sample comprised a community sample of 763 people with OA who participated in the Somerset and Avon Survey of Health. The SF-36 was explored for DIF with respect to demographic, social, clinical and psychological factors. Well developed ordinal regression models were used to identify DIF items.


DIF items were found by age (6 items), employment status (6 items), social class (2 items), mood (2 items), hip v knee (2 items), social deprivation (1 item) and body mass index (1 item). Although the impact of the DIF items rarely had a significant effect on the conclusions of group comparisons, in most cases there was a significant change in effect size.


Overall, the SF-36 performed well with only a small number of DIF items identified, a reassuring finding in view of the frequent use of the SF-36 in OA. Nevertheless, where DIF items were identified it would be advisable to analyse data taking account of DIF items, especially when age effects are the focus of interest.

Osteoarthritis; SF-36; Psychometrics; Item bias; Differential item functioning; Measurement equivalence