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Adapting a Benefit Trade-Off Instrument to Measure Health Inequality Aversion in the United States
Salome Ricci1, Stacey Kowal2, Susan dosReis1
1University of Maryland School of Pharmacy, Patient-Driven Values in Healthcare Evaluation (PAVE) Center, Department of Practice, Sciences, and Health Outcomes Research, Baltimore, MD, USA.
Value in Health Regional Issues
|December 13, 2025
Summary
We successfully adapted a complex health inequality measurement tool for the US population. This adaptation improved response validity, aiding future health equity research and decision-making.
Area of Science:
- Health Economics
- Health Policy
- Health Technology Assessment
Background:
- Health equity is a key consideration in healthcare decision-making.
- The benefit trade-off (BTO) approach quantifies health inequality aversion.
- Existing BTO tools require adaptation for different national contexts.
Purpose of the Study:
- To adapt a UK-developed BTO instrument for measuring health inequality aversion in the US general population.
- To ensure the adapted instrument is contextually relevant and technically comprehensible for a US audience.
Main Methods:
- Iterative modification of the BTO instrument, incorporating US-specific elements.
- Three rounds of pretesting (n=11) and pilot testing (n=150) for optimization.
- Online survey implementation (n=2064) with US Census-aligned demographic quotas.
Main Results:
- Adaptations included localized videos and comprehension checks, significantly improving usability.
- Valid response rates for inequality aversion analysis increased from 33% to 63%.
- The final sample was representative of US adults, with slight overrepresentation in older age and higher education.
Conclusions:
- The structured adaptation process yielded a valid instrument for measuring US societal health inequality preferences.
- Achieved valid response rates comparable to the original UK study.
- This work provides a foundation for best practices in adapting preference measurement tools for international health equity research.
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