title: Are symbols useful and culturally acceptable in health-state valuation studies? An exploratory study in a multi-ethnic Asian population.
abstract: 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.
  
  
  OBJECTIVE
  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.
authors.affiliation: Department of Pharmacy, National University of Singapore (NUS), Singapore;
authors.forename: Wee
authors.initials: W
authors.lastname: Hwee-Lin
authors.forename: Shu-Chuen
authors.initials: SC
authors.lastname: Li
authors.forename: Xu-Hao
authors.initials: XH
authors.lastname: Zhang
authors.forename: Feng
authors.initials: F
authors.lastname: Xie
authors.forename: David
authors.initials: D
authors.lastname: Feeny
authors.forename: Nan
authors.initials: N
authors.lastname: Luo
authors.forename: Yin-Bun
authors.initials: YB
authors.lastname: Cheung
authors.forename: David
authors.initials: D
authors.lastname: Machin
authors.forename: Kok-Yong
authors.initials: KY
authors.lastname: Fong
authors.forename: Julian
authors.initials: J
authors.lastname: Thumboo