EQ-HWB

EQ-HWB Health and Wellbeing Measure for Economic Evaluation

The EQ-HWB was built because the instruments behind most QALY estimates describe health and little else, while many health, public health and social care programmes change loneliness, coping, control over daily life or the strain on a family carer. Brazier and colleagues opened their 2022 overview of the measure by observing that existing measures for estimating quality-adjusted life years are mostly limited to health-related quality of life. The result was a 25-item questionnaire grouped into seven broad domains, developed with patients, social care users, members of the public and carers in six countries, and a nine-item short form, first called the EQ-HWB-S and renamed the EQ-HWB-9 by EuroQol in 2025, whose items sit inside the long form and carry a value set. For a health economist the long form matters as a descriptive outcome in trials and evaluations that reach beyond health, and as the item pool from which the valued short form was drawn.

Why the Extending the QALY project built a new measure

The EQ-HWB came out of a project called Extending the QALY (E-QALY). The project's website, hosted by the University of Sheffield, states its aim as developing a broad measure of quality of life for use in economic evaluations across health and social care, capturing benefits for patients, social care users and carers. The domains were to come from what those groups say matters to them, not from an existing health instrument.

The same website records that the project began in May 2017 and was expected to last two and a half years before being extended by one year. It names its funding as an MRC Industry Collaboration Award (MRC grant number 148787) with the EuroQol Group, with further funding from the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Yorkshire and Humber. NICE describes the E-QALY project as one it contributed to.

The motive is a familiar problem in cost-utility analysis. A QALY can only register what the underlying instrument describes, so a social care intervention that improves a person's sense of control, or a respite service that eases a carer's exhaustion, may show little gain on a health-focused measure even when the change is large. The EQ-HWB was designed to describe those effects in a form that a health economist can use alongside a health-only profile.

Six stages of development

The project ran as six stages, listed on its website as identifying domains, generating items, testing face validity with users, psychometric testing, item selection and valuation of the selected items by members of the public. Each stage narrowed the pool of candidate items, and the published papers report the numbers at each step.

Mukuria and colleagues ran the stage 1 qualitative review of evidence on how health conditions, informal caring and social care use affect quality of life. Carlton and colleagues then reported stages 2 and 3. Items were drawn from commonly used generic, carer, social care and mental health quality of life measures and mapped onto the domains, and predetermined selection criteria cut 687 candidates to 89, since 687 − 598 = 89. Face validation tested 97 draft items and four response scales in interviews, and the 47 retained items, 14 modified items and 3 new items gave a pool of 47 + 14 + 3 = 64 items for the survey.

Peasgood and colleagues reported the stage 4 survey, completed by patients, social care users and carers in Argentina (508), Australia (514), China (497), Germany (502), the United Kingdom (1,955) and the United States (903). They used exploratory and confirmatory factor analysis to test dimensionality, item response theory to examine item information and response categories, and tests of differential item functioning across subgroups. Brazier and colleagues summarised the result as confirming the conceptual model in every country except China, with most items performing well. Two rounds of stakeholder consultation then informed the final choice of the 25-item EQ-HWB and the 9-item short version.

Seven domains, a seven-day recall and five response levels

The descriptive system rests on the seven high-level themes of the stage 1 review. Mukuria and colleagues named them activity; feelings and emotions; cognition; self-identity; "coping, autonomy and control"; relationships and social connections; and physical sensations. Later papers shorten some of these labels, for example to autonomy or relationships. Brazier and colleagues report that the development work organised 32 subdomains under these 7 domains.

The review gives examples of what each theme holds. Feelings and emotions include sadness, anxiety, hope, frustration, safety and guilt or shame. Cognition covers concentration, memory, confusion and thinking clearly. Self-identity covers dignity or respect and self-esteem. Relationships and social connections include loneliness, social engagement, stigma and belonging. Physical sensations include pain, discomfort, sleep and fatigue, and activity covers self-care, meaningful activities, mobility, communication, hearing and vision. Apart from physical sensations, most themes were relevant across health and social care, including for informal carers, which supports one instrument for patients, service users and carers.

Each item asks about the last seven days. Items are answered on five-level response scales, each describing frequency, severity or difficulty. The choice of scale differs between items, so one item may ask how often a feeling occurred while another asks how much difficulty an activity caused.

Illustrative count of states and why a short form was needed

Valuation methods such as time trade-off ask people to value whole states, so the number of states an instrument can describe shapes what a valuation study can do. The figures below are exact counts of response patterns and illustrate why the long form was not valued directly.

$$5^{25} = 298023223876953125$$

where 5 is the number of response levels on each item, 25 is the number of items in the EQ-HWB and the result is the number of distinct response patterns.

$$5^{9} = 1953125$$

where 9 is the number of items in the short version and the result is its number of response patterns. Both counts are far beyond what any survey could value directly, so a value set is always a statistical model estimated from a sample of states. A model for 25 items would need many more parameters and many more valuation tasks than one for 9, and the E-QALY website states that the short version was designed for valuation in the project's final stage.

Psychometric evidence on the 25-item measure

Evidence on the long form has grown since the development surveys. In the stage 4 data, Peasgood and colleagues found low missing data where skipping was permitted, use of all response levels by most items, positive and negative measurement factors, and weaker discrimination among carers than in other groups.

Keetharuth and colleagues reported in 2025 on a UK sample of 767 patients across six broad health conditions and 302 members of the general population who completed the EQ-HWB measures with other instruments. Test-retest reliability exceeded 0.8 in both groups. At scale level, the EQ-HWB summative score correlated most strongly with the PHQ-8 and the GAD-7, followed by the EQ-5D-5L and the ICECAP-A. The authors noted remaining gaps in evidence on reliability, particularly at item level for the full EQ-HWB, and on known-group validity across a broad range of patient groups and social care needs.

The pattern of correlations is informative for an analyst choosing outcomes. Strong links with depression and anxiety scales reflect the weight of feelings, emotions and coping items in the measure, which is part of what it was designed to add beyond a health profile.

Where the EQ-HWB sits in an economic evaluation

The 25-item measure is first a descriptive profile. The 25 items have no value set as a whole, and a summative score of the kind used in psychometric work has no anchor at full health and dead. The nine short-form items are embedded in the long form, however, and Kinchin and colleagues derived EQ-HWB-S responses from EQ-HWB answers in an Irish general population survey of 1,220 adults. A 25-item administration can therefore yield short-form utilities and QALYs from the embedded items, while the other items describe in more detail which aspects of health and wellbeing changed, results that can sit beside costs in a cost-consequence analysis.

The choice between the versions is mainly one of respondent burden. The long form gives a fuller profile and the embedded short-form utilities in one questionnaire, while the short form alone gives the utilities with fewer questions.

NICE describes the EQ-HWB as a new standardised measure of health and wellbeing created following the Extending the QALY project. Its science policy pages state that the EQ-HWB has not been developed as a replacement for the EQ-5D, but as a different instrument that captures a broader range of impacts on people, their families and carers, and that research is under way to validate the EQ-HWB and compare it with existing instruments. NICE says this research will help it decide whether and how to use the EQ-HWB to inform its evaluations in the future. NICE has not adopted the EQ-HWB in its reference case.

How the EQ-HWB differs from neighbouring measures

The EQ-HWB shares the EuroQol name with the EQ-5D but differs in scope. The EQ-5D describes health and carries value sets used widely in health technology assessment, whereas the EQ-HWB adds domains such as loneliness, coping, control and self-identity and was developed with social care users and carers as well as patients.

Other measures cover parts of the same ground. ICECAP-A describes capability wellbeing, meaning what a person is able to do and be, which is a different construct from the functioning and feelings the EQ-HWB asks about. ASCOT describes social care-related quality of life and is used to evaluate social care services. Measures of caregiver quality of life focus on the effects of caring, while the EQ-HWB is intended to be completed in the same form by carers, patients and service users, which allows their results to be compared on one descriptive system.

Wellbeing in its general sense is broader than any of these instruments. The EQ-HWB measures a defined set of domains chosen for economic evaluation, and material circumstances such as income or housing sit outside its seven domains even when they matter to the people completing it.

Limitations and common misreadings

The measure is new, and its evidence base is still growing. Several points are easy to misread when the EQ-HWB appears in a study or a submission.

• An experimental version. McDool and colleagues described the EQ-HWB-9 evaluated in their 2026 study as the experimental 2022 version, and later studies have tested potential modifications to the items, including a modified version labelled EQ-HWB EMV2.1. A result is interpretable only when the version used is reported.
• Only the embedded items carry utilities. A summative score of the 25 items, or a mean of item levels, cannot be multiplied by time to give QALYs. Utilities from a 25-item administration come from the nine embedded short-form items and their value set.
• Weaker evidence in some groups. Peasgood and colleagues found weaker discrimination among carers in the development survey, and Keetharuth and colleagues identified gaps in known-group evidence across social care needs, groups the measure was built to include.
• Recall period. The seven-day recall differs from instruments that ask about a single day, so scores from different instruments collected at the same visit do not describe the same period.
• Not a replacement for the EQ-5D. NICE has said the EQ-HWB was not developed to replace the EQ-5D and that research will inform whether and how it uses the EQ-HWB in future evaluations.

Sources

• Brazier J, Peasgood T, Mukuria C, et al. The EQ-HWB: overview of the development of a measure of health and wellbeing and key results. Value in Health. 2022;25(4):482-491. doi:10.1016/j.jval.2022.01.009
• Carlton J, et al. Generation, selection, and face validation of items for a new generic measure of quality of life: the EQ-HWB. Value in Health. 2022;25(4):512-524. doi:10.1016/j.jval.2021.12.007
• Keetharuth A, Mukuria C, Peasgood T, Wailoo A. EQ Health and Wellbeing EQ-HWB: a psychometric assessment across 6 conditions and the general population in the United Kingdom. Value in Health. 2025;28(12). doi:10.1016/j.jval.2025.07.028
• Kinchin et al. A comparative study of health and well-being measures in Ireland using EQ Health and Wellbeing (EQ-HWB) and its short version, EQ-5D-5L, and ICEpop Capability Measure for Adults (ICECAP-A). Value in Health. 2025. https://pubmed.ncbi.nlm.nih.gov/40320237/
• McDool E, Mukuria C, Wickramasekera N, Tsuchiya A. Evaluating the validity of the EQ-HWB-9 in a large United Kingdom general population sample. Value in Health. 2026;29(8):1452-1462. doi:10.1016/j.jval.2026.02.006
• Mukuria C, et al. Qualitative review on domains of quality of life important for patients, social care users, and informal carers to inform the development of the EQ-HWB. Value in Health. 2022;25(4):492-511. https://pubmed.ncbi.nlm.nih.gov/35365298
• National Institute for Health and Care Excellence. Science policy and methods projects (web page, EQ-HWB entry). https://www.nice.org.uk/what-nice-does/our-research-work/our-projects-and-partners/science-policy-projects (accessed 17 October 2026)
• Peasgood T, et al. Developing a new generic health and wellbeing measure: psychometric survey results for the EQ-HWB. Value in Health. 2022;25(4):525-533. https://pubmed.ncbi.nlm.nih.gov/35365299/
• University of Sheffield. Extending the QALY (E-QALY) project website, About and Findings (stages 1 to 6). https://e-qaly.sites.sheffield.ac.uk/about (accessed 17 October 2026)