15-Dimensional Health-Related Quality of Life

Abstract

The 15-Dimensional Health-Related Quality of Life (commonly abbreviated as the 15D) is a standardized, self-administered, generic, comprehensive, preference-based instrument designed to assess health-related quality of life (HRQoL) in both adult clinical populations and general community cohorts. Developed by Finnish health economist Harri Sintonen, the instrument operationalizes the multidimensional construct of health across 15 distinct, mutually exhaustive dimensions: Mobility, Vision, Hearing, Breathing, Sleeping, Eating, Speech, Elimination (Excretion), Usual Activities, Mental Function, Discomfort and Symptoms, Depression, Distress, Vitality, and Sexual Activity. Each dimension is represented by a single item structured into five hierarchically ordered ordinal response levels, yielding more than 30.5 billion (5¹⁵ ≈ 3.05 × 10¹⁰) possible unique health states. The 15D serves a dual measurement purpose: it functions simultaneously as a profile measure, capturing granular functional deficits across separate physiological, psychological, and social domains, and as a single-index preference-based utility measure scored on a continuous interval scale from 0 (state equivalent to being dead) to 1 (full health/no problems). The single-index score is derived using an additive multi-attribute utility theory (MAUT) model parameterized through population-derived preference weights obtained via visual analogue scale (VAS) and magnitude estimation rating procedures. Psychometric evaluations demonstrate exceptional properties: high internal consistency across physical and psychosocial dimensions (α ≈ .80–.87), robust test-retest reliability (intraclass correlation coefficients typically exceeding .85 to .92), solid convergent and discriminant validity against legacy instruments such as the EQ-5D, SF-36, and Nottingham Health Profile (NHP), and remarkable sensitivity to subtle clinical changes (large effect sizes and responsiveness indices across chronic, surgical, and psychiatric interventions). Consequently, the 15D is widely utilized in clinical trials, epidemiological surveys, and cost-utility analyses to calculate Quality-Adjusted Life Years (QALYs).

Keywords

15D, Health-Related Quality of Life, HRQoL, Multi-Attribute Utility Theory, Health Utilities, Psychometrics, QALY, Generic Health Instrument, Cost-Utility Analysis, Harri Sintonen

Authors

The primary architect and principal investigator of the 15D instrument is Harri Sintonen, PhD, Professor Emeritus of Health Economics at the Department of Public Health, Faculty of Medicine, University of Helsinki, Helsinki, Finland. Professor Sintonen initially conceptualized the predecessor 12-dimensional version in the late 1970s and early 1980s before formally refining, expanding, and standardizing the 15-dimensional instrument in collaboration with health service researchers, biostatisticians, and clinical epidemiologists.

Key institutional affiliations and collaborative bodies associated with the ongoing psychometric validation, valuation modeling, and international dissemination of the 15D include:

• Department of Public Health, Faculty of Medicine, University of Helsinki, Finland.
• National Centre for Health Program Evaluation (NCHPE), Melbourne, Australia (where key methodological treatises and international preference valuation weights were established during Sintonen’s tenure as a visiting senior fellow).
• Finnish Office for Health Technology Assessment (FinOHTA) and the National Institute for Health and Welfare (THL), Helsinki, Finland.
• Collaborative research groups across international centers in Scandinavia, the United Kingdom, Canada, and Southern Europe involved in cross-cultural adaptation and linguistic validations.

Inquiries regarding licensing, scoring algorithms, population norm tables, and computerized scoring macros are administered directly via Professor Sintonen’s official academic clearinghouse (15D-Instrument.net).

Purpose

The fundamental purpose of the 15D is to provide a comprehensive, sensitive, psychometrically sound, and conceptually coherent measurement system capable of capturing health-related quality of life across the entire continuum of illness, medical intervention, and wellness. Unlike disease-specific measures—which focus narrowly on symptoms idiosyncratic to a particular condition (e.g., arthritic joint stiffness or oncologic chemotherapy nausea)—the 15D was engineered as a generic instrument. This allows for direct comparisons across divergent clinical populations, interventions, and medical specialties, as well as benchmarking against healthy general population norms.

Clinical and Epidemiological Applications

In routine clinical practice and longitudinal clinical trials, the 15D fulfills three primary functions:

• Baseline Stratification and Needs Assessment: Establishing the multidimensional functional baseline of patients presenting with complex, multisystem, or multimorbid conditions, identifying unaddressed psychosocial or sensory impairments that may elude routine laboratory or clinical biomarkers.
• Longitudinal Monitoring: Evaluating the trajectory of recovery, disease progression, or therapeutic response over time. The 15D has demonstrated exceptional responsiveness to acute surgical interventions (e.g., coronary artery bypass grafting, joint replacement), chronic disease management (e.g., chronic obstructive pulmonary disease, rheumatoid arthritis, Parkinson’s disease), and psychiatric programs (e.g., major depressive disorder, anxiety disorders).
• Population Health Surveillance: Serving as a standard health assessment tool in comprehensive nationwide health surveys, enabling epidemiologists to map the distribution of health states across demographic strata, evaluate health inequalities, and forecast future healthcare resource demands.

Health Economic Evaluation and Cost-Utility Analysis

A core raison d’être of the 15D is its capacity to generate preference-based health utility scores. Modern healthcare resource allocation increasingly relies on cost-utility analysis (CUA), where the benefits of medical interventions are quantified in terms of Quality-Adjusted Life Years (QALYs). To calculate a QALY, survival time must be weighted by the health utility of the life years lived, bounded on an interval scale between 0.0 (death) and 1.0 (perfect/full health). While instruments such as the EQ-5D and the SF-6D (derived from the SF-36) are widely used for this purpose, the 15D was explicitly designed to overcome the ceiling effects and descriptive insensitivity that frequently compromise 3-level and 5-dimension measures. By combining 15 discrete dimensions with a sophisticated multi-attribute utility valuation algorithm, the 15D provides health economists with an extraordinarily sensitive index that captures incremental utility shifts resulting from medical interventions.

Psychological Construct

The psychological and physiological construct underlying the 15D operationalizes health-related quality of life not merely as the absence of somatic disease, but as a dynamic, multifaceted state of physical, functional, emotional, and social well-being, adhering closely to the holistic definition posited by the World Health Organization (WHO). The instrument deconstructs HRQoL into 15 distinct dimensions, each representing a primary axis of human functional capacity and lived subjective experience:

1. Mobility

Evaluates physical locomotion, gross motor function, and physical independence across varying environmental challenges (indoors, outdoors, and navigating stairs). The continuum extends from unencumbered, normal ambulation to slight outdoor/stair difficulties, reliance on mechanical appliances or human assistance, indoor restriction, and complete bed-ridden immobility.

2. Vision

Assesses visual sensory acuity and functional optical competence required for daily tasks, primarily using reading printed media (newspapers) and decoding electronic visual displays (television text) with or without corrective lenses as real-world behavioral anchors. It spans from normal functional vision to slight and marked reading difficulties, inability to read coupled with preserved navigational sight, and near-total or complete blindness requiring a guide.

3. Hearing

Measures auditory perception and linguistic processing in natural conversational settings, with or without auditory amplification devices. Levels range from effortless comprehension of normal conversational speech to slight difficulty, significant difficulty requiring elevated vocal volume, near deafness (hearing only loud shouting), and total auditory deficit.

4. Breathing

Reflects pulmonary efficiency and exertional dyspnea. The spectrum spans absence of respiratory distress, dyspnea during heavy physical exertion (e.g., uphill walking or brisk pace), dyspnea walking on level ground at peer pace, dyspnea triggered by minimal basic activities of daily living (e.g., personal hygiene, dressing), and pervasive respiratory distress persisting at rest.

5. Sleeping

Probes restorative nocturnal sleep patterns and subjective sleep architecture. The dimension captures uninterrupted restful sleep, minor sleep onset or sleep maintenance latency, moderate fragmented sleep and perceived sleep deficit, chronic severe disruption requiring habitual pharmacotherapy, and profound, intractable insomnia resistant to medication.

6. Eating

Evaluates oral motor capability, manual dexterity, and the biomechanics of self-nourishment. Levels descend from autonomous, unassisted nutritional intake to independent eating with minor motor tremor/slowness/appliance use, partial dependence on personal assistance, substantial reliance on human feeding, and absolute inability to ingest orally, necessitating enteral (tube) or parenteral (intravenous) nutrition.

7. Speech

Assesses verbal communication, articulation, fluency, and vocal clarity. The continuum tracks clear, audible, fluent articulation, minor dysfluencies or vocal pitch alterations, hesitant or disjointed speech that remains intelligible, severe communication breakdown where understanding is restricted, and complete loss of functional verbal capacity requiring gesture-based communication.

8. Elimination (Excretion)

Captures excretory continence and lower urinary and gastrointestinal tract competence. It ranges from normal physiological continence to minor voiding or transit difficulties (mild constipation/diarrhea), moderate intermittent incontinence or severe transit dysregulation, severe habitual incontinence requiring invasive management (catheterization, enemas), and complete loss of sphincteric autonomic control.

9. Usual Activities

Reflects role functioning, vocational productivity, educational engagement, domestic management, and engagement in leisure pursuits. The levels delineate unconstrained performance of baseline personal and societal roles, slight performance decrement, marked loss of effectiveness and substantial struggle, severe functional restriction to a minor subset of roles, and total incapacitation regarding usual daily activities.

10. Mental Function

Addresses higher-order neurocognitive integrity, logical cognition, information processing, working memory, and temporal-spatial orientation. The dimension covers clear, logical executive functioning and intact memory, subtle cognitive lapses, noticeable memory and reasoning deficits, severe cognitive disorganization and memory impairment, and profound disorientation with delirium or dementia.

11. Discomfort and Symptoms

Evaluates somatic distress, including nociceptive pain, chronic aching, nausea, pruritus, and generalized somatic discomfort. The scale progresses ordinally from absolute absence of physical symptoms to mild, moderate, severe, and utterly unbearable somatic distress.

12. Depression

Captures the affective spectrum of dysphoria, melancholia, sadness, hopelessness, and psychological dejection. It progresses monotonically from feeling completely free of depressive affect to experiencing slight, moderate, severe, and catastrophic/extreme depressive melancholy.

13. Items of the Scale (Questionnaire)

14. Vitality

Measures physical and mental energy reserves, subjective vigor, stamina, and feelings of exhaustion (the reverse of chronic fatigue). The construct anchors at feeling energetic and fully healthy, descending through mild weariness, moderate fatigue, profound exhaustion, to total, debilitating physical and mental collapse.

15. Sexual Activity

Reflects the degree to which an individual’s health status impacts, restricts, or impairs their capacity for sexual expression and intimacy. Levels graduate from zero adverse health interference, through minor and considerable disruption, to sexual function being rendered almost completely or entirely impossible due to health factors.

Theoretical Framework

The construction, structure, and operational mechanics of the 15D instrument are grounded in three interrelated theoretical disciplines: psychometric measurement theory, psychophysics, and economic decision theory.

Multi-Attribute Utility Theory (MAUT)

The foundational mathematical architecture of the 15D rests upon Multi-Attribute Utility Theory (MAUT), originally formulated by Keeney and Raiffa (1976). MAUT provides a normative framework for modeling preferences over complex outcomes characterized by multiple conflicting attributes. Within this paradigm, an individual’s overall health state is conceptualized as a multi-attribute health profile vector:

X = (x₁, x₂, …, x₁₅)

where each x_j represents the discrete functional level (1 to 5) observed in dimension j. To aggregate these distinct categorical states into a scalar utility metric, the 15D implements an additive multi-attribute utility function. The overall health utility score U(X) is computed as:

U(X) = ∑_j=1¹⁵ w_j × v_j(x_j)

where:

• w_j represents the relative importance weight assigned to dimension j, normalized such that the sum of all weights across the 15 dimensions equals unity: ∑ w_j = 1.0.
• v_j(x_j) denotes the single-attribute valuation function, reflecting the relative desirability or value of level x in dimension j, scaled continuously from 1.0 (Level 1: optimal function) down to 0.0 (Level 5: worst function).

This additive formulation rests on the critical theoretical axiom of additive preference independence (or mutual utility independence). Sintonen and colleagues empirically evaluated and confirmed that despite clinical interdependencies (e.g., between breathing and mobility), interaction effects between dimensions do not statistically distort the linear additive model, rendering the additive approximation exceptionally robust, transparent, and mathematically tractable.

Psychophysical Scaling and Population Valuation

Unlike purely psychometric profile scales (e.g., Likert-type symptom checklists) that assign arbitrary equidistant integers to response categories, the 15D derives its single-attribute values and dimensional importance weights through rigorous psychophysical scaling. Sintonen employed a two-stage elicitation methodology using large, representative, non-institutionalized population samples:

1. Single-Attribute Value Elicitation: Respondents evaluated the relative subjective severity of each intermediate response level (Levels 2, 3, and 4) against the fixed anchors of Level 1 (best = 1.0) and Level 5 (worst = 0.0) within each dimension using a combination of visual analogue scales (VAS) and ratio estimation techniques.
2. Dimensional Weight Elicitation: Participants evaluated the relative importance of moving from the worst to the best level across all 15 dimensions using magnitude estimation and hierarchical trade-off rankings. This yielded empirical weights demonstrating, for instance, that deficits in Mental Function, Breathing, and Mobility consistently exert higher population disutility than comparable deficits in Speech or Sexual Activity.
3. Death Anchor Calibration: To ensure utility values correspond to the standard health economics continuum where Death = 0.0 and Full Health = 1.0, states perceived as worse than death (states with negative raw valuations) are mathematically calibrated and bounded, enabling seamless integration into life-table analyses and QALY calculations.

Validity

The psychometric validity of the 15D has been comprehensively evaluated in hundreds of clinical trials, observational cohorts, and cross-sectional health surveys across Europe, North America, and the Asia-Pacific region.

Content and Face Validity

Content validity was established during the initial design phase through extensive iterative consultations with multi-disciplinary clinical specialists, health economists, psychologists, and patient panels. By expanding the original 12 dimensions to 15, Sintonen specifically addressed critical blind spots common to other generic instruments—incorporating sensory faculties (Vision, Hearing), primary autonomic functions (Eating, Excretion, Breathing), and essential biological drivers (Sexual Activity, Vitality). Expert reviews and cognitive debriefing interviews confirm that the 15 items comprehensively encompass the domains identified by the WHO International Classification of Functioning, Disability and Health (ICF).

Construct and Convergent Validity

Convergent validity has been repeatedly demonstrated through strong, statistically significant correlations between the 15D dimensions and corresponding subscales of legacy HRQoL and clinical instruments:

• Comparison with the EQ-5D: Pearson and Spearman correlation coefficients between the overall 15D single-index score and the EQ-5D index typically range from r = .75 to .88 across diverse clinical samples (e.g., musculoskeletal disorders, cardiovascular disease, oncology). Dimension-to-dimension correlations between homologous scales (e.g., 15D Mobility vs. EQ-5D Mobility; 15D Depression/Distress vs. EQ-5D Anxiety/Depression) routinely exceed r = .70.
• Comparison with the SF-36: The physical component summary (PCS) and mental component summary (MCS) of the Short Form-36 correlate strongly with the 15D physical sub-clusters (Mobility, Breathing, Discomfort: r = .65–.80) and mental sub-clusters (Depression, Distress, Mental Function: r = .68–.82), respectively.
• Objective Biomarker Correlation: The 15D dimensions exhibit strong associations with physiological markers: the Breathing dimension correlates significantly with forced expiratory volume in 1 second (FEV₁; r ≈ .55–.65) in COPD patients; the Mobility dimension tracks 6-minute walk test (6MWT) distances; and the Mental Function dimension aligns with Mini-Mental State Examination (MMSE) scores in geriatric cohorts.

Discriminant and Known-Groups Validity

The 15D demonstrates exceptional known-groups validity, clearly differentiating between individuals across varying disease severities, age brackets, comorbidity burdens, and functional independence strata:

• In comparative studies of chronic renal failure, the 15D utility index successfully stratified patients across distinct treatment modalities: kidney transplant recipients exhibited significantly higher mean scores (≈ 0.88) compared to peritoneal dialysis patients (≈ 0.79) and hemodialysis patients (≈ 0.74; p < .001).
• In oncology, the instrument differentiates between localized, metastatic, and terminal cancer stages, with progressive declines evident across physical symptoms, vitality, and usual activities.
• Crucially, the 15D exhibits substantially reduced ceiling effects in general and ambulatory populations compared to the EQ-5D-3L (often < 5% vs. > 25–40%), confirming superior discriminant power in milder health states.

Responsiveness and Longitudinal Sensitivity

The responsiveness of the 15D to meaningful clinical changes has been rigorously benchmarked. In pharmacotherapy and surgical intervention trials, the 15D has repeatedly produced standardized response means (SRM) and effect sizes (Cohen’s d) between 0.50 (moderate) and > 1.20 (large). The Minimum Clinically Important Difference (MCID) for the overall 15D single-index utility score has been empirically identified as 0.015 (a shift of ±0.015 indicates a clinically meaningful, subjective alteration in health status), providing a clear threshold for interpreting clinical trials and economic models.

Reliability

The reliability of the 15D has been established across multiple independent investigations evaluating internal consistency and temporal stability.

Internal Consistency

Because the 15D comprises 15 heterogeneous, non-redundant dimensions spanning both physical and psychological constructs, treating all 15 items as a single reflective scale yields a moderately high overall Cronbach’s alpha, typically falling between α = .80 and .87 across clinical and general populations (Sintonen, 1994, 2001). When decomposed into thematic sub-clusters, internal consistency estimates remain robust:

• Physical/Functional cluster (Mobility, Vision, Hearing, Breathing, Eating, Elimination, Usual Activities): α ≈ .81–.85.
• Psychosocial/Affective cluster (Depression, Distress, Vitality, Mental Function): α ≈ .82–.86.

Test-Retest Stability

Temporal stability evaluated among stable, non-transitioning cohorts has confirmed high repeatability:

• Over a 1- to 2-week retest interval among stable outpatients and healthy community respondents, the intraclass correlation coefficient (ICC) for the overall 15D single-index score routinely falls between 0.85 and 0.92, demonstrating remarkable measurement stability.
• Individual dimension-level repeatability, evaluated via weighted Cohen’s kappa (κ_w), yields values ranging from .65 (for highly fluctuating subjective states such as Distress and Vitality) to > .88 (for stable somatic/sensory functions such as Vision, Hearing, and Eating).
• Bland-Altman plot analyses confirm that repeated administrations show no systematic measurement drift or substantial proportional bias across the health utility continuum.

Factor Analysis

The internal dimensionality and structural organization of the 15D have been examined through both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) across diverse international datasets.

Exploratory Factor Structure

While the 15D was clinically designed to capture 15 unique, separable facets of health, underlying latent variable modeling consistently extracts three to five higher-order structural factors depending on clinical complexity and cohort age:

• Physical/Functional Performance Factor: Demonstrates high positive factor loadings (> .60) from Mobility, Breathing, Usual Activities, and Elimination.
• Psychological/Affective Factor: Characterized by dominant loadings (> .70) from Depression, Distress, and Vitality (the latter cross-loading inversely with somatic fatigue).
• Sensory and Autonomic Communication Factor: Captures sensory inputs and motor outputs, with primary loadings from Vision, Hearing, Speech, and Eating.
• Cognitive-Biological Maintenance Factor: In 4- or 5-factor solutions, Mental Function and Sleeping frequently segregate into a neurocognitive/restorative component, while Sexual Activity may load independently or associate with physical vigor.

Confirmatory Factor Analysis and Structural Equation Modeling

Structural equation modeling has tested whether the 15 dimensions adequately map onto a single overarching second-order “General Health-Related Quality of Life” construct or a bifactor architecture:

• A second-order hierarchical model specifying two primary second-order latent dimensions—Physical Health (subsuming Mobility, Vision, Hearing, Breathing, Eating, Speech, Elimination, Usual Activities, Discomfort) and Psychosocial/Mental Health (subsuming Mental Function, Depression, Distress, Vitality, Sleeping, Sexual Activity)—demonstrates good fit across diverse empirical datasets.
• Typical reported fit indices across large epidemiological samples (N > 2,000) include: Comparative Fit Index (CFI) = .93–.96; Tucker-Lewis Index (TLI) = .92–.95; Root Mean Square Error of Approximation (RMSEA) = .045–.058 (90% CI [.040, .062]); and Standardized Root Mean Square Residual (SRMR) ≤ .042.
• Factor loadings of all 15 manifest indicator items onto their respective primary latent dimensions are uniformly positive, robust, and statistically significant (standardized loadings λ = .48 to .86, p < .001).

Instrument / Measurement Tool

The operational specifications of the 15D are summarized below:

• Instrument Type: Generic, comprehensive, preference-based multi-attribute health-related quality of life survey instrument.
• Target Population: Adults (aged 16 years and older); specialized pediatric versions (e.g., 16D for adolescents, 17D for children) exist as separate adaptations.
• Administration Modes: Self-administered paper-and-pencil questionnaire, supervised clinical interview, telephone administration, or secure digital/web-based electronic surveys.
• Administration Time: Approximately 5 to 10 minutes (average completion time ≈ 7 minutes).
• Item Count: 15 items, with exactly one item dedicated to each of the 15 dimensions.
• Response Format: Each dimension has 5 ordinal response levels (Level 1 = best health state/no difficulty to Level 5 = worst health state/extreme difficulty).
• Recall Period: Present health state (“at the present time” / “now”).
• Primary Output Metrics:
  • 15D Profile: A 15-dimensional vector of single-attribute value scores (each scaled from 0.0 to 1.0), which can be displayed graphically as a radar chart or profile plot to illustrate specific physical and psychological functional decrements.
  • 15D Overall Utility Index: A single continuous score bounded between 0.00 (equivalent to being dead) and 1.00 (full health/no problems across all dimensions). Calculation requires applying population-specific valuation weight algorithms (additive multi-attribute utility formulas) supplied by the author.
• Handling Missing Data: The official scoring macro tolerates a maximum of 3 missing dimensions out of 15. Missing values are imputed using an integrated multi-regression algorithm based on the non-missing dimensions, age, and sex. If more than 3 dimensions are unanswered, the single-index score cannot be reliably generated.

Permissions & Fee and Test Year

The 15D instrument was first introduced in its 12-dimensional prototype in 1981, with the refined, definitive 15-dimensional version officially validated and published by Harri Sintonen in 1989, followed by extensive updates and international utility valuations throughout the 1990s and early 2000s (e.g., Sintonen, 1994, 1995, 2001).

Copyright and Licensing Policy

The copyright of the 15D instrument, its translated versions, and its valuation algorithms is held exclusively by Harri Sintonen. The instrument is protected under international intellectual property and copyright law. Key licensing parameters include:

• Academic and Non-Commercial Research: Use of the 15D for academic, non-commercial clinical, university-sponsored research, and non-funded student dissertations is generally granted either free of charge or for a nominal administrative registration fee, subject to formal registration and approval.
• Commercial and Industry-Sponsored Studies: Use by pharmaceutical companies, contract research organizations (CROs), commercial clinical trials, and for-profit entities is subject to licensing fees based on study size, protocol complexity, and data requirements.
• Access and Registration: Prospective users must obtain written permission, official scoring macros (e.g., SPSS, SAS, Stata, or R syntax), and certified language translations by registering their study directly at the official 15D website (www.15d-instrument.net). Alteration of item wording, order, or response options is strictly prohibited to preserve measurement integrity.

References

• Keeney, R. L., & Raiffa, H. (1976). Decisions with multiple objectives: Preferences and value trade-offs. John Wiley & Sons.
• Sintonen, H. (1994). The 15D measure of health-related quality of life. I. Reliability, validity and its applications in technology assessment. Health Policy, 30(1), 85–96. https://doi.org/10.1016/0168-8510(94)90040-X
• Sintonen, H. (1995). The 15D-measure of health-related quality-of-life, II. Feasibility, reliability, and validity of its valuation system. National Centre for Health Program Evaluation, Working Paper 42, Melbourne.
• Sintonen, H. (2001). The 15D instrument of health-related quality of life: Properties and applications. Annals of Medicine, 33(5), 328–336. https://doi.org/10.3109/07853890109002086
• Sintonen, H. (2013). 15Dimensional health-related quality of life. In C. A. Simmons & P. Lehmann (Eds.), Tools for strengths-based assessment and evaluation (pp. 100–104). Springer Publishing Company.
• Sintonen, H., & Pekurinen, M. (1989). A generic 15 dimensional measure of health-related quality of life (15D). Journal of Social Medicine, 26, 85–96.
• Sintonen, H., & Pekurinen, M. (1993). A fifteen dimensional measure of health-related quality of life (15D) and its applications. In S. R. Walker & R. M. Rosser (Eds.), Quality of life assessment: Key issues in the 1990s (pp. 185–195, 467–470). Kluwer Academic Publishers. https://doi.org/10.1007/978-94-011-2988-6_12
• Stavem, K. (1999). Reliability, validity and responsiveness of two multiattribute utility instruments in patients with chronic obstructive pulmonary disease: Quality of Well-Being scale and the 15D instrument. Quality of Life Research, 8(1–2), 45–54. https://doi.org/10.1023/a:1026442602758

Items of the Scale