Adapting a Benefit Trade-Off Instrument to Measure Health Inequality Aversion in the United States

Health equity is increasingly central to healthcare decision making, necessitating robust methods to incorporate equity considerations into health technology assessment. The benefit trade-off (BTO) approach measures health inequality aversion-how much total population health individuals would sacrifice to reduce health inequalities. However, these complex preference measurement tools need to be adapted and contextualized for use in different country settings. In this work, we aimed to adapt a BTO instrument, originally developed in the United Kingdom, to measure health inequality aversion in the United States general population.

We modified the BTO instrument through an iterative process that addressed US-specific contextual elements and technical comprehension requirements. We conducted 3 rounds of pretesting (n = 11) followed by pilot testing (n = 150) to optimize the instrument. The final BTO was implemented in an online survey completed by 2064 participants, recruited through a Qualtrics panel, with demographic quotas aligned to US Census data.

Adaptation to enhance technical and conceptual comprehension included the development of localized instructional videos and implementation of new comprehension checks. Among complete responses, 63% provided valid responses suitable for inequality aversion parameter analysis, up from 33% in the initial pilot. The final sample was representative of US adults, although with higher age and educational attainment.

Our adaptation used a structured approach, similar to other ongoing studies, for measuring societal health inequality preferences. By achieving valid response rates in line with the original UK study, our US study adds to the evidence base for best practice guidance, informing future adaptations across different country settings.