healthcare

Article
Reliability and Mental Health Correlates of a Single-Item
Measure of Self-Rated Mental Health (SRMH) in the
Chinese Context
Hong Wang Fung 1, * , Stanley Kam Ki Lam 2 , Wai Tong Chien 2 , Henry Wai-Hang Ling 3 , Zi Yi Wu 4 ,
Colin A. Ross 5 and Anson Kai Chun Chau 6,7

1 Department of Social Work, Hong Kong Baptist University, Kowloon Tong, Hong Kong SAR, China
2 The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong,
Hong Kong SAR, China; [email protected] (S.K.K.L.); [email protected] (W.T.C.)
3 The Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong SAR,
China; [email protected]
4 Yuli Hospital Ministry of Health and Welfare, Hualien 981, Taiwan; [email protected]
5 The Colin A. Ross Institute for Psychological Trauma, Richardson, TX 75080, USA; [email protected]
6 Department of Psychology, The Chinese University of Hong Kong, Hong Kong SAR, China;
[email protected]
7 Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China
* Correspondence: [email protected]

Abstract: The use of single-item measures of self-rated mental health (SRMH) has been increas-
ingly valued in epidemiologic research. However, little is known about the reliability and mental
health correlates of SRMH in Chinese populations. This study examined the reliability and mental
health correlates of SRMH in three Chinese samples. We analyzed data collected from two conve-
nience samples of Chinese adults from Hong Kong and/or Taiwan (Sample 1: N = 205; Sample 2:
N = 377), and a random sample of Taiwan psychiatric inpatients (Sample 3: N = 100). Our results
showed that the single-item measure of SRMH had moderate to good test–retest reliability (intr-
aclass correlation [ICC] = 0.75) in Sample 1 and acceptable reliability between the self-report and
Citation: Fung, H.W.; Lam, S.K.K.; interviewer-administered versions (ICC = 0.58) in Sample 3. It had a high positive correlation with
Chien, W.T.; Ling, H.W.-H.; Wu, Z.Y.;
self-esteem and a moderately high negative correlation with depression. It also had a consistently
Ross, C.A.; Chau, A.K.C. Reliability
negative correlation with borderline personality disorder symptoms and post-traumatic stress disor-
and Mental Health Correlates of a
der symptoms. The SRMH score was also associated with psychiatric service usage. These findings
Single-Item Measure of Self-Rated
contribute to the body of knowledge regarding the use of a single-item measure of SRMH to assess
Mental Health (SRMH) in the Chinese
Context. Healthcare 2024, 12, 122.
overall self-perceived mental health in Chinese communities.
https://doi.org/10.3390/
healthcare12010122 Keywords: assessment; epidemiology; mental health; public health; reliability; self-rated mental
health (SRMH)
Academic Editor: John H. Foster

Received: 6 November 2023

Revised: 13 December 2023
Accepted: 3 January 2024 1. Introduction
Published: 4 January 2024 Mental health problems are significant public health issues not only associated with
individual suffering but also significant family and societal consequences. For either public
health research or general screening in the community, self-report measures are probably
the most commonly used tools to assess mental health or mental disorders. For these
Copyright: © 2024 by the authors.
purposes, scales with fewer items are useful and are increasingly valued, whereas scales
Licensee MDPI, Basel, Switzerland.
with many items can provide comprehensive information but have disadvantages in terms
This article is an open access article
distributed under the terms and
of practicality and acceptability for research and clinical screening. In particular, Smits
conditions of the Creative Commons
et al. [1] and Haroz et al. [2] have emphasized the importance of developing reliable short
Attribution (CC BY) license (https://
mental health measures, and have described the disadvantages of using lengthy scales,
creativecommons.org/licenses/by/ such as an increasing response burden of the responder, and being difficult to complete
4.0/). for people with shorter attention spans. In addition, lengthy scales may affect the quality

Healthcare 2024, 12, 122. https://doi.org/10.3390/healthcare12010122 https://www.mdpi.com/journal/healthcare

Healthcare 2024, 12, 122 2 of 10

of the data obtained because some participants might not be willing to participate or to
complete all of the scale items.
Single-item measures of self-rated health (SRH) or mental health (SRMH) have re-
ceived increasing attention in recent epidemiologic studies [3–5]. The literature review
of Ahmad et al. [6] suggested that single-item measures of SRMH were first used in the
1970s, and subsequently have been included as part of the sets of questions in measures
which have been used in different national epidemiologic studies. Different versions of
the single-item measures of SRMH often have similar meanings, for example, “In general,
would you say your mental health is. . .” and “How do you rate your mental health at
the present time?”. Ahmad et al. [6] conducted a review to examine how single-item
measures of SRMH were correlated with other mental health measures in public health
research. Among 57 included studies, they reported that “SRMH correlated moderately
with the following mental health scales: Kessler Psychological Distress Scale, Patient Health
Questionnaire, mental health subscales of the Short-Form Health Status Survey, Behaviour
and Symptom Identification Scale, and World Mental Health Clinical Diagnostic Interview
Schedule” (p. 1). For example, in one of the studies, the single-item SRMH was correlated
significantly with three different measures of depressive symptoms (r = 0.42 to 0.50) [7].
Studies examining SMRH across ethnic groups have shown that there are cultural and
ethnic differences in the understanding and reporting of SRMH. For instance, mental health
problems other than major depression have shown a heterogeneous relationship with
SRMH in different ethnic groups [8,9]. Therefore, the findings in Ahmad et al. [6]’s review
might not be generalizable to Chinese populations.
Although there is increasing evidence about their usefulness, two major research
gaps concerning the use of single-item measures of SRMH require attention and fur-
ther investigation. First, these single-item measures are commonly used in population
surveys, but little is known about their reliability, including the test–retest reliability
and reliability between the self-report and interviewer-administered versions. We are
not aware of any study reporting the reliability of single-item measures of SRMH. Sec-
ond, there is insufficient evidence or understanding about the mental health correlates of
SRMH, in Chinese and other Asian contexts. Recently, single-item measures of SRMH have
been used in several Chinese studies, e.g., [10,11]. However, few studies have evaluated
their reliability or correlations with other well-validated multi-item mental health mea-
sures in Chinese societies. Only one study has reported a significant negative correlation
(r = −0.48, p < 0.001) between a single-item measure of SRMH (i.e., “How would you rate
your overall mental or emotional health?” and depressive symptoms in a sample of older
Chinese Americans (N = 108) [12]. To address these two research gaps, this study examined
the reliability of a single-item measure of SRMH (i.e., test–retest reliability and reliability
between the self-report and interviewer-administered versions) and how it would correlate
with measures of other mental health variables (including common psychiatric symptoms)
among Chinese research participants. We hypothesized that the single-item measure of
SRMH used would have acceptable reliability (i.e., intraclass correlation coefficient > 0.5)
and significant correlations with measures of common mental health symptoms, including
depression and anxiety. We also hypothesized that the single-item measure of SRMH would
be correlated with psychiatric service usage. In summary, the primary objective of this
study is to establish the reliability and validity of the Chinese version of the SRMH.

2. Materials and Methods

2.1. Participants and Settings
This study analyzed data collected from three samples of Chinese participants mainly
from Hong Kong and Taiwan.
Sample 1: An online convenience sample of young adults mainly from Hong Kong and
Taiwan. Participants were recruited in a project conducted by the Achievement Foundation,
a registered charitable institution in Hong Kong; and approval was obtained from the
executive committee of this organization. During the period between April 2021 and July
Healthcare 2024, 12, 122 3 of 10

2021, this project aiming to investigate mental health problems in a convenience sample of
Chinese young adults aged 18–24; participants (N = 205) were recruited through online
social media platforms to participate in a web-based survey on trauma and related mental
health problems. Participants: (1) were able to read and write Chinese; (2) had access to
the internet; and (3) were willing to participate after providing informed consent on the
first instruction page and then completed the anonymous online survey. There were no
exclusion criteria. Email addresses of participants were obtained in order to conduct a retest
at a one-week interval. The methodology, sampling and results of the study have been
reported elsewhere [13]. In Sample 1, N = 205 young adults participated in the web-based
survey. Most participants came from Taiwan (65.4%) and Hong Kong (29.3%), while 5.4%
reported their place of residence as “other”. Most of them were female (84.9%).
Sample 2: A convenience sample of Hong Kong adults who received primary care (traditional
Chinese medicine [TCM]) services in the past three months. Participants were recruited from a
project which was approved by the institutional review board of the Chinese University
of Hong Kong. This project examined psychosocial and mental health experiences in
a convenience sample of Hong Kong adults (N = 377). In 2022, the project recruited
participants through Hong Kong-based channels (e.g., social media platforms and local
TCM clinics) to participate in a web-based survey that included measures of various
mental health problems. Participants had to (1) be aged 18 or above, (2) be Hong Kong
Chinese residents who received TCM services in the past three months, and (3) be willing
to participate after providing informed consent on the first instruction page and then
complete the anonymous online survey. Only participants who self-reported that they
had been diagnosed with a learning or reading disorder, dementia, and/or cognitive
impairments were excluded. The methodology, sampling and results of the study have
been reported elsewhere [14]. In Sample 2, N = 377 Hong Kong community health (TCM)
service users participated in the web-based survey. As in the Taiwan sample, most of them
were female (80.9%).
Sample 3: A random sample of Taiwan psychiatric inpatients diagnosed with schizophrenia
spectrum disorders. In 2021, 100 inpatients with schizophrenia spectrum disorders were
recruited from a total of 486 inpatients staying one to several years in the largest psychiatric
hospital in Taiwan, the Yuli Hospital of the Ministry of Health and Welfare. Ethics approval
was obtained from the Institutional Review Board of this hospital. Participants were aged
18 or above, agreed to provide written consent and to participate, and had a clinical diag-
nosis of schizophrenia spectrum and other psychotic disorders according to DSM-5 criteria.
Patients were excluded if they had (1) difficulties in communication because of cognitive
impairments; (2) a clinical diagnosis of dementia; (3) speech or hearing impairments; or
(4) been discharged from the hospital before the assessments could be completed. In this
project, an interviewer (an occupational therapist) used an online randomizer to select
potential participants and then invited them to participate in the survey and a follow-up
structured interview. Once informed written consent had been obtained, participants were
invited to complete a questionnaire consisting of several self-report measures of trauma
and mental health symptoms. Ten days after completion of the self-report measures, the
interviewer conducted a structured interview with each participant using selected sections
of the Dissociative Disorders Interview Schedule (DDIS) and the Psychotic Symptom Rating
Scales (PSYRATS). In sample 3, 100 Taiwan psychiatric inpatients with a clinical diagnosis
of schizophrenia (N = 79) or schizoaffective disorder (N = 21) participated in the survey
and structured interview. More than half of them were male (55%).
The sociodemographic and clinical characteristics of each of the three samples are
summarized in Table 1.
Healthcare 2024, 12, 122 4 of 10

Table 1. Sample characteristics of Sample 1, Sample 2 and Sample 3.

Sample 1 (N = 205) Sample 2 (N = 377) Sample 3 (N = 100)

A convenience sample of Hong
A convenience sample of young A random sample of psychiatric
Kong adults who received
Descriptions Chinese-speaking adults aged inpatients with schizophrenia or
traditional Chinese medicine
between 18 to 24 schizoaffective disorder
services (TCM) in the community
Current locations
Hong Kong 29.3% 100% 0%
Taiwan 65.4% 0% 100%
Others 5.4% 0% 0%
Age—Mean (SD) 21.2 (1.92) 40.49 (12.58) 58.3 (7.31)
Age—Range 18 to 24 18 to 64 36 to 71
Gender—Female % 84.9% 80.9% 45%
Education level
High school or below 16.1% 31.3% N/A
Associate degree or equivalent 15.1% 15.6% N/A
Bachelor’s degree 64.9% 35.0% N/A
Postgraduate degree or above 3.9% 18.0% N/A
Employment/student status
Full-time employed 18.0% 63.7% N/A
Part-time employed 28.8% 13.8% N/A
Self-employed N/A N/A N/A
Unemployed and homemakers 53.2% 22.5% N/A
Students 73.2% # N/A N/A
A total of 23.4% reported that they
All participants received TCM
were currently seeking
services (primary care) in the past
professional help for emotional or All of them were long-term
Service usage three months;
mental health problems; 22.0% institutionalized inpatients
11.1% reported themselves as
had seen a psychiatrist in the
currently seeing a psychiatrist.
past year
Single-item measure of self-rated
mental health (test/retest @)
Poor 7.3%/7.8% 7.7% 17.0%/19.0%
Fair 25.9%/19.0% 35.8% 15.0%/21.0%
Good 30.7%/33.6% 26.0% 47.0%/50.0%
Very Good 32.7%/36.2% 24.1% 13.0%/8.0%
Excellent 3.4%/3.4% 6.4% 8.0%/2.0%
Notes: # In Sample 1, employment and student status were asked differently using two separate questions, and
therefore a given participant may be student and being employed at the same time (i.e., the sum of all percentages
is greater than 100%) @ In Sample 1, only N = 116 participants completed the retest.

2.2. Measures
This study examined the reliability, including the test–retest reliability and reliability
between the self-report and interviewer-administered versions, of SRMH and its correlation
with measures of other mental health symptoms in the above-mentioned three Chinese
samples; the single-item measure of SRMH was administered to all three Chinese samples.
In addition to the SRMH, several mental health measures of self-esteem, depression, anxiety,
post-traumatic stress disorder (PTSD) symptoms, and borderline personality disorder (BPD)
symptoms, and psychotic symptoms were used and are described as follows:
Single-item measure of self-rated mental health (SRMH) (possible range: 1 to 5). The single-
item measure of SMRH asked, “How would you rate your overall mental health?” (1 = poor,
2 = fair, 3 = good, 4 = very good, 5 = excellent) [6]. As mentioned, this single-item measure
and its modified versions have been used in previous studies, including in Chinese popula-
tions [12], and found to be correlated moderately with other well-established measures of
depression and psychological distress [6]. The single-item measure of SMRH has also been
used in some recent studies [4]. However, the Chinese version has not been psychometri-
cally evaluated; higher ratings of the single item would indicate a better self-rated mental
health. Participants in all three samples completed this single-item measure.
Healthcare 2024, 12, 122 5 of 10

Single-item measure of self-esteem (SISE) (possible range: 1 to 9). The SISE, which asked,
“How satisfied are you with yourself?” (1 = very dissatisfied, 9 = very satisfied), is a
valid single-item self-report measure of self-esteem [15]. The literature indicates that both
multi-item and single-item measures of self-esteem have very consistent relationships
with other psychological and health variables [16]. In Sample 1 of this study, in which
N = 116 participants completed a retest after an average of 9.32 days (SD = 3.97), the Chinese
version of the SISE was found to have good test–retest reliability (ICC = 0.82, p < 0.001),
and good construct validity (a moderate negative correlation with depression). Participants
in all samples completed the SISE.
Patient Health Questionnaire-9 (PHQ-9) (possible range: 0 to 27). The PHQ-9 is a self-report
measure of DSM depressive symptoms. The PHQ-9 was reported to have good internal
consistency (α = 0.86), test–retest reliability (r = 0.84) and concurrent validity with the
Beck Depression Inventory [17–19]. The Chinese version of the PHQ-9 also demonstrated
excellent internal consistency (α = 0.91) and good diagnostic validity (the sensitivity was
81% and the specificity was 98% when a cutoff of 15 was used to detect major depressive
disorder) [20]. The Chinese version of the PHQ-9 has also been found to be a reliable and
valid scale across gender and age groups in a recent study [21]. Participants in Sample 1
(α = 0.92; M = 8.01; SD = 6.39; Skewness = 1.04; Kurtosis = 0.57) and Sample 2 (α = 0.92;
M = 11.19; SD = 6.98; Skewness = 0.30; Kurtosis = −0.84) completed the Chinese version of
the PHQ-9. A sample item is “Feeling down, depressed, or hopeless”.
The PTSD subscale of the International Trauma Questionnaire (ITQ) (possible range: 0 to 24).
The ITQ is originally a 18-item self-report measure of ICD-11 complex PTSD symptoms; a
6-item subscale can be particularly used to assess classical PTSD symptoms [22]. The Chinese
version of the ITQ also has good internal consistency and validity [23]. Participants in Sample
2 completed the Chinese version of the ITQ (α = 0.89; M = 9.23; SD = 6.29; Skewness = 0.13;
Kurtosis = −0.98). A sample item is “Being “super-alert”, watchful, or on guard”?
PTSD Checklist for DSM-5 (PCL-5) (possible range: 0 to 80). The PCL-5 is a 20-item self-report
measure of DSM-5 PTSD symptoms; it has excellent internal consistency (α = 0.94), good test–
retest reliability (r = 0.82), good convergent validity (r = 0.74 to 0.85) and had excellent diagnos-
tic validity when a cutoff of 31 was used (sensitivity = 94.1%, specificity = 93.9%) [24,25]. The
Chinese version of the PCL-5 also had excellent internal consistency (α = 0.95) and acceptable
diagnostic validity when a cutoff of 49 was used (sensitivity = 70.6%, specificity = 72.7%) [26].
Participants in Sample 1 (α = 0.96; M = 34.19; SD = 20.26; Skewness = 0.06; Kurtosis = −0.95)
and Sample 3 (α = 0.95; M = 40.32; SD = 13.49; Skewness = −0.61; Kurtosis = −0.53) com-
pleted the Chinese version of the PCL-5. A sample item is “Repeated, disturbing, and
unwanted memories of the stressful experience”?
Borderline Personality Disorder Section of the Self-Report Dissociative Disorders Interview
Schedule (DDIS-BPD) (possible range: 0 to 9). The DDIS-BPD is a 9-item section from the
DDIS, which is an interviewer-administered structured diagnostic interview [27]. The
DDIS-BPD, which includes nine yes/no/unsure items, is designed to assess the nine
BPD symptoms according to DSM-5 rules, and has been used in many studies [28–31].
The Chinese version of the self-report DDIS-BPD (SR-DDIS-BPD) was found to have good
convergent validity with the 20-item Taiwan version of the Borderline Personality Inventory,
good construct validity with other mental health symptoms, and acceptable diagnostic
validity when a cutoff of 5 was used (sensitivity = 95.2%, specificity = 64.9%); it was also
demonstrated to have good concurrent validity as it could discriminate between patients
with and without a BPD diagnosis [32]. Participants in all Sample 1 (M = 2.31; SD = 2.32;
Skewness = 0.76; Kurtosis = −0.42) and Sample 2 (M = 1.87; SD = 2.32; Skewness = 1.21;
Kurtosis = 0.55) completed the DDIS-BPD as a self-report measure and those in Sample 3
completed the DDIS-BPD in the structured interview (M = 1.32; SD = 1.36; Skewness = 1.26;
Kurtosis = 1.83). A sample item is “Frantic efforts to avoid real or imagined abandonment”.
The Dissociative Features Subsection of the DDIS (DDIS-DF). The DDIS-DF is a 16-item
subsection that is particularly designed to assess psychoform dissociative symptoms,
and this measure can identify dissociative pathology very well [27,28]. The Chinese ver-
Healthcare 2024, 12, 122 6 of 10

sion of this measure also has good validity [30]. To assess dissociative symptoms, the
DDIS-DF was administered as a self-report measure in Sample 2 (M = 1.07; SD = 1.57;
Skewness = 2.21; Kurtosis = 5.80) and as part of a structured interview in Sample 3
(M = 6.99; SD = 3.53; Skewness = 0.48; Kurtosis = −0.44). A sample item is “Do you
ever feel that there is another person or persons inside you”?
Psychotic Symptom Rating Scales (PSYRATS). The PSYRATS is a 17-item semi-structured
interview for auditory hallucinations and delusions [33]. The Chinese version of the
PSYRATS had excellent interrater reliability (ICC = 0.92 to 0.95), good test–retest reliability
(ICC = 0.81 to 0.82), very satisfactory content validity, and good convergent validity with
the Positive and Negative Syndrome Scale [34]. Participants in Sample 3 was interviewed
using Chinese version of the PSYRATS (Positive Syndrome subscale: α = 0.88; M = 23.57;
SD = 6.06; Skewness = −1.04; Kurtosis = 1.23; Negative Syndrome subscale: α = 0.89;
M = 10.05; SD = 4.03; Skewness = −0.83; Kurtosis = 0.48).

2.3. Data Analysis

The data were analyzed using SPSS 22.0. This study examined the reliability of the
single-item measure of SRMH by calculating its test–retest reliability in Sample 1 and inter-
rater reliability in Sample 3 using intraclass correlation coefficients (ICC) (two-way mixed
effects, absolute agreement) according to Koo and Li [35]’s guideline; ICC values below
0.05, between 0.5 and 0.75, between 0.75 and 0.9, and greater than 0.90 were considered
to be poor, moderate, good, and excellent reliabilities. In this study, an ICC value above
0.5 was considered to be acceptable. In addition, we examined the mental health correlates
of the single-item measure of SRMH using Spearman’s correlation coefficients. Finally, we
examined whether SRMH would be associated with psychiatric service utilization using
Chi-square tests—in Sample 1, participants were asked if they “had seen a psychiatrist”
in the past 12 months; in Sample 2, participants were asked if they were currently seeing
a psychiatrist.

3. Results
3.1. Reliability
In Sample 1, a subgroup of participants (N = 116) completed the retest after an average
of 9.32 days (SD = 3.97). The single-item measure of SRMH had moderate to good test–retest
reliability (ICC = 0.75, 95% CI: 0.65–0.82, p < 0.001).
In Sample 3, the single-item measure of single-item SRMH had moderate reliability
between the self-report version and the interviewer-administered version (ICC = 0.58,
95% CI: 0.43–0.70, p < 0.001). Notably, both versions of the single-item SRMH utilized
identical wording; the only difference was the mode of completion, with one being a paper
questionnaire and the other being verbally asked by the interviewer. Therefore, the results
here indicated a moderate test–retest reliability comparing the self-report version and the
interviewer-administered version of the single-item SRMH.

3.2. Demographic and Mental Health Correlates

The relationships of the single-item measure of SMRH with age, gender, and other
mental health variables are indicated in Table 2. SRMH was not correlated with age or
gender across the samples.
Healthcare 2024, 12, 122 7 of 10

Table 2. Correlations between the single-item measure of self-rated mental health (SRMH) and other
mental health variables in three samples.

Sample 1 (N = 205) Sample 2 (N = 377) Sample 3 (N = 100)

Variables SRMH SRMH SRMH
Age 0.09 0.67 *** −0.09
Gender (Female) −0.03 −0.09 0.09
Self-esteem 0.75 *** 0.69 *** 0.82 **
Depressive symptoms −0.66 *** −0.60 *** -
Post-traumatic stress
−0.52 *** −0.38 *** −0.32 **
disorder symptoms
Borderline
personality disorder −0.48 *** −0.46 *** −0.22 *
symptoms
Psychoform
dissociative - −0.25 *** −0.10
symptoms
Hallucinations - - −0.03
Delusions - - −0.18
* p < 0.050 ** p < 0.010 *** p < 0.001. Note: Correlations with gender are point-biserial correlations. The remaining
correlations are Spearman’s correlations.

The findings indicated that the single-item measure of SMRH had a strong to very
strong positive correlation with self-esteem (Samples 1–3: rho = 0.69 to 0.82, p < 0.001),
while it had a strong negative correlation with depression (Sample 1: rho = −0.66, p < 0.001,
Sample 2: rho = −0.59, p < 0.001). It also had a weak to moderate negative correlation
with PTSD symptoms (Samples 1–3: rho = −0.32 to −0.52, p < 0.001) and BPD symptoms
(Samples 1–3: rho = −0.22 to −0.48, p < 0.05). Its correlation with dissociative symp-
toms was significant in Sample 2 (rho = −0.25, p < 0.001) but not in the inpatient sample
(rho = −0.10, p = 0.345). The single-item measure of SMRH did not have a significant
correlation with hallucinations (rho = −0.03, p = 0.742) or delusions (rho = −0.18, p = 0.068)
in the inpatient sample.
In Sample 1, 45 participants (22.0%) reported that they “had seen a psychiatrist” in the
past year. A chi-square test indicated that they were more likely to rate their own mental
health as “poor” or “fair” on the SMRH than those who did not see a psychiatrist in the
past year (60.0% vs. 25.6%), χ2 (1) = 18.72, p < 0.001).
In Sample 2, 42 participants (11.1%) reported that they were currently seeing a psychi-
atrist. A chi-square test indicated that they were more likely to rate their own mental health
as “poor” or “fair” on the SMRH than those who were not currently seeing a psychiatrist
(69.0% vs. 40.3%), χ2 (1) = 12.55, p < 0.001).

4. Discussion
This study aimed to examine the reliability and construct validity by investigating the
reliability and mental health correlates of the Chinese version of the single-item measure of
SRMH. The findings demonstrated that the single-item measure of SRMH had moderate to
good test–retest reliability and acceptable agreement between the self-report version and
the interviewer-administered version in our Chinese samples. In addition, the single-item
measure of SRMH also had a strong to very strong positive correlation with self-esteem in
all three Samples, a strong negative correlation with depression (in Sample 1 and Sample 2),
and a weak to moderate negative correlation with PTSD and BPD symptoms (Sample 1,
Sample 2 and Sample 3). The single-item measure of SRMH was also associated with
self-report psychiatric service utilization in Sample 1 and Sample 2. These results indicate
that the single-item measure of SRMH can be reliably used in Chinese populations to assess
overall mental health.
This study contributes to the increasing body of knowledge on the use of a single-item
measure of SRMH; previous studies did not establish its reliability and/or did not examine
Healthcare 2024, 12, 122 8 of 10

its mental health correlates, especially in Chinese populations, except for one study in older
Chinese Americans in 2016 [12]. The literature revealed that cultural and ethnic differences
might be observed when measuring SRMH [8,9], and previous findings on the SRMH may
not be generalizable to Chinese populations. Therefore, the present study contributes to
the literature by showing that the single-item measure of SRMH can be reliably used and is
correlated with measures of other mental health variables in Chinese populations.
The single-item measure of SRMH was found to be reliable and positively corre-
lated with self-esteem, and negatively correlated with common mental health symptoms
(e.g., depression and PTSD symptoms) and with self-report psychiatric service utilization
in the Chinese samples. These findings suggest that the single-item measure of SRMH can
be used as a public health measure to assess self-perceived general mental health among
Chinese people, and can reflect ones’ overall mental well-being and correlate with other
mental health conditions such as depression and anxiety, as indicated in this study.
Since early identification of mental health problems is important, regular mental health
screening is recommended in health and social service settings. As the single-item measure
of SRMH is very short and easily administered and has been found to be strongly associated
with common measures of mental health conditions, this single-item measure can be useful
and acceptable in a general health screening survey and in clinical and community service
settings to facilitate early recognition of population-wide mental well-being. The SRMH
measure could assist in early identification of mental healthcare needs. Whenever a person
self-perceives his/her overall mental health or well-being as “poor” or “fair”, a detailed
and comprehensive follow-up mental health assessment can be recommended.
It should be noted that the single-item measure of SRMH in psychiatric inpatient
settings (Sample 3) might not perform as well as in community care settings (Sample 1 and
Sample 2). The SMRH was not associated with dissociation, hallucinations, or delusions in
Sample 3. One possible reason for this is that inpatients with schizophrenia or schizoaffec-
tive disorder might have relatively poor insight into rating their own mental health.
This study has several limitations. First, we relied on self-report data in Sample 1 and
Sample 2 and this method is usually considered to have certain disadvantages (e.g., people
providing invalid responses, social desirability bias, response bias) [36,37]. Second, Sam-
ple 1 and Sample 2 were convenience samples and were not representative of the general
population, and therefore future studies should further evaluate the use of single-item
measure of SMRH in different Chinese populations. Third, we analyzed cross-sectional data
only, and we could not examine the predictive ability of SMRH for detecting subsequent
mental health problems; future longitudinal studies will be required to examine whether
the single-item measure of SRMH can predict mental health problems and/or service
utilization. Fourth, while we examined the mental health correlates of the SRMH, some
other indicators of mental well-being, like life satisfaction and meaning in life, were not
considered in our samples. Finally, this study drew upon a selection of the literature that
includes studies published more than five years ago. Notably, certain measures utilized
in this research were psychometrically evaluated over five years ago. Therefore, future
investigations into the clinical and public health utility of the single-item measure of SMRH
should incorporate more recent studies to ensure the most up-to-date understanding and
applicability of the measure.

5. Conclusions
This study demonstrated that the single-item measure of SRMH is a reliable measure
and is significantly correlated with common valid measures of mental health problems in
Chinese people. This easily implemented assessment tool can be included in public health
studies and general health screening or assessments to investigate overall mental well-
being in Chinese populations. Further studies are required to examine whether measures of
SRMH can predict mental health outcomes and the need for psychiatric care and services.
Healthcare 2024, 12, 122 9 of 10

Author Contributions: Conceptualization, H.W.F.; methodology, H.W.F.; formal analysis, H.W.F.;

data curation, H.W.F., H.W.-H.L. and Z.Y.W.; writing—original draft preparation, H.W.F.; writing—
review and editing, H.W.F., S.K.K.L., W.T.C. and A.K.C.C.; supervision, S.K.K.L., W.T.C. and C.A.R.
All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki. The study for Sample 1 was approved by the executive committee of Achievement
Foundation, who is a registered charitable institution in Hong Kong (20 April 2021). The study for
Sample 2 was approved the Institutional Review Board of the Chinese University of Hong Kong
(SBRE-21-0473, 11 February 2022). The study for Sample 3 was approved the Institutional Review
Board of Yuli Hospital Ministry of Health and welfare, Hualien County, Taiwan (YLH-IRB-10921, 13
January 2021).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data will be made available upon request to the corresponding author.
Acknowledgments: H.W.F. received the RGC Postdoctoral Fellowship Scheme 2022/23 offered by the
Research Grants Council, Hong Kong. A.K.C.C. was supported by the Vice Chancellor’s Discretionary
Fund of the Chinese University of Hong Kong.
Conflicts of Interest: The authors declare no conflicts of interest.

References
1. Smits, N.; Cuijpers, P.; Beekman, A.T.; Smit, J.H. Reducing the length of mental health instruments through structurally incomplete
designs. Int. J. Methods Psychiatr. Res. 2007, 16, 150–160. [CrossRef] [PubMed]
2. Haroz, E.E.; Kane, J.C.; Nguyen, A.J.; Bass, J.K.; Murray, L.K.; Bolton, P. When less is more: Reducing redundancy in mental
health and psychosocial instruments using Item Response Theory. Glob. Ment. Health 2020, 7, e3. [CrossRef] [PubMed]
3. Stubbs, J.M.; Achat, H.M. A single-item measure of self-rated mental health and psychological distress. In what situations can a
single-item measure be useful? Australas. Psychiatry 2023, 31, 53–57. [CrossRef] [PubMed]
4. Galambos, N.L.; Johnson, M.D.; Krahn, H.J. Self-rated mental health in the transition to adulthood predicts depressive symptoms
in midlife. Curr. Psychol. 2022, 42, 30223–30234. [CrossRef] [PubMed]
5. Wang, L.; Chen, H.; Ye, B.; Gao, J.; Dai, J.; Wang, F.; Fu, H. Mental health and self-rated health status of internal migrant workers
and the correlated factors analysis in Shanghai, China: A cross-sectional epidemiological study. Int. Health 2019, 11, S45–S54.
[CrossRef] [PubMed]
6. Ahmad, F.; Jhajj, A.K.; Stewart, D.E.; Burghardt, M.; Bierman, A.S. Single item measures of self-rated mental health: A scoping
review. BMC Health Serv. Res. 2014, 14, 398. [CrossRef] [PubMed]
7. Jang, Y.; Park, N.S.; Kim, G.; Kwag, K.H.; Roh, S.; Chiriboga, D.A. The association between self-rated mental health and symptoms
of depression in Korean American older adults. Aging Ment. Health 2012, 16, 481–485. [CrossRef]
8. Assari, S. Ethnic groups differ in how poor self-rated mental health reflects psychiatric disorders. J. Racial Ethn. Health Disparities
2018, 5, 728–736. [CrossRef]
9. Kim, G.; DeCoster, J.; Chiriboga, D.A.; Jang, Y.; Allen, R.S.; Parmelee, P. Associations between self-rated mental health and
psychiatric disorders among older adults: Do racial/ethnic differences exist? Am. J. Geriatr. Psychiatry 2011, 19, 416–422.
[CrossRef]
10. Han, Q.; Zheng, B.; Agostini, M.; Bélanger, J.J.; Gützkow, B.; Kreienkamp, J.; Reitsema, A.M.; van Breen, J.A.; Collaboration, P.;
Leander, N.P. Associations of risk perception of COVID-19 with emotion and mental health during the pandemic. J. Affect. Disord.
2021, 284, 247–255. [CrossRef]
11. Lai, D.W.; Li, J.; Bai, X. To be or not to be: Relationship between grandparent status and health and wellbeing. BMC Geriatr. 2021,
21, 204. [CrossRef] [PubMed]
12. Jang, Y.; Huang, Y.-C.; Yoon, H.; Lin, S. Correlates of self-rated health and self-rated mental health in older Chinese Americans.
Soc. Work Public Health 2016, 31, 309–315. [CrossRef] [PubMed]
13. Fung, H.W.; Chien, W.T.; Ling, H.W.H.; Ross, C.A.; Lam, S.K.K. The mediating role of post-traumatic stress disorder symptoms in
the relationship between childhood adversities and depressive symptoms in two samples. Child Abus. Negl. 2022, 131, 105707.
[CrossRef] [PubMed]
14. Fung, H.W.; Wong, E.N.M.; Lam, S.K.K.; Chien, W.T.; Hung, S.L.; Ross, C.A.; Cloitre, M. Prevalence and sociocultural correlates of
post-traumatic stress disorder (PTSD) and complex PTSD among Chinese community health service users in Hong Kong. Int. J.
Soc. Psychiatry 2022, 69, 895–905. [CrossRef] [PubMed]
15. Sawicki–Luiza, P.A.A.A.; Atroszko, S.B. Validity and reliability of single-item self-report measure of global self-esteem. In
Proceedings of the CER Comparative European Research, London, UK, 29–31 March 2017; pp. 120–123.
Healthcare 2024, 12, 122 10 of 10

16. Robins, R.W.; Hendin, H.M.; Trzesniewski, K.H. Measuring global self-esteem: Construct validation of a single-item measure and
the Rosenberg Self-Esteem Scale. Personal. Soc. Psychol. Bull. 2001, 27, 151–161. [CrossRef]
17. Kung, S.; Alarcon, R.D.; Williams, M.D.; Poppe, K.A.; Moore, M.J.; Frye, M.A. Comparing the Beck Depression Inventory-II
(BDI-II) and Patient Health Questionnaire (PHQ-9) depression measures in an integrated mood disorders practice. J. Affect. Disord.
2013, 145, 341–343. [CrossRef]
18. Kroenke, K.; Spitzer, R.L.; Williams, J. The PHQ-9: Validity of a brief depression severity measure. J. Gen. Intern. Med. 2001, 16,
606–613. [CrossRef]
19. Manea, L.; Gilbody, S.; McMillan, D. Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire
(PHQ-9): A meta-analysis. Can. Med. Assoc. J. 2012, 184, E191–E196. [CrossRef]
20. Yeung, A.; Fung, F.; Yu, S.-C.; Vorono, S.; Ly, M.; Wu, S.; Fava, M. Validation of the Patient Health Questionnaire-9 for depression
screening among Chinese Americans. Compr. Psychiatry 2008, 49, 211–217. [CrossRef]
21. Leung, D.Y.; Mak, Y.W.; Leung, S.F.; Chiang, V.C.; Loke, A.Y. Measurement invariances of the PHQ-9 across gender and age
groups in Chinese adolescents. Asia-Pac. Psychiatry 2020, 12, e12381. [CrossRef]
22. Cloitre, M.; Hyland, P.; Prins, A.; Shevlin, M. The international trauma questionnaire (ITQ) measures reliable and clinically
significant treatment-related change in PTSD and complex PTSD. Eur. J. Psychotraumatology 2021, 12, 1930961. [CrossRef]
[PubMed]
23. Ho, G.W.; Karatzias, T.; Cloitre, M.; Chan, A.C.; Bressington, D.; Chien, W.T.; Hyland, P.; Shevlin, M. Translation and validation of
the Chinese ICD-11 International Trauma Questionnaire (ITQ) for the Assessment of Posttraumatic Stress Disorder (PTSD) and
Complex PTSD (CPTSD). Eur. J. Psychotraumatology 2019, 10, 1608718. [CrossRef] [PubMed]
24. Blevins, C.A.; Weathers, F.W.; Davis, M.T.; Witte, T.K.; Domino, J.L. The Posttraumatic Stress Disorder Checklist for DSM-5
(PCL-5): Development and initial psychometric evaluation. J. Trauma. Stress 2015, 28, 489–498. [CrossRef] [PubMed]
25. Geier, T.J.; Hunt, J.C.; Nelson, L.D.; Brasel, K.J.; deRoon-Cassini, T.A. Detecting PTSD in a traumatically injured population: The
diagnostic utility of the PTSD Checklist for DSM-5. Depress. Anxiety 2019, 36, 170–178. [CrossRef] [PubMed]
26. Fung, H.W.; Chan, C.; Lee, C.Y.; Ross, C.A. Using the Post-traumatic Stress Disorder (PTSD) Checklist for DSM-5 to screen
for PTSD in the Chinese context: A pilot study in a psychiatric sample. J. Evid.-Based Soc. Work 2019, 16, 643–651. [CrossRef]
[PubMed]
27. Ross, C.A.; Heber, S.; Norton, G.R.; Anderson, D.; Anderson, G.; Barchet, P. The Dissociative Disorders Interview Schedule: A
structured interview. Dissociation 1989, 2, 169–189. [CrossRef]
28. Ross, C.A.; Ellason, J.W. Discriminating among diagnostic categories using the Dissociative Disorders Interview Schedule. Psychol.
Rep. 2005, 96, 445–453. [CrossRef]
29. Fung, H.W.; Ling, H.W.H.; Ross, C.A.; Tse, J.W.-L.; Liu, R.K.W. Dissociative, schneiderian and borderline personality symptoms in
a non-clinical sample in Hong Kong: A preliminary report. Eur. J. Trauma Dissociation 2020, 4, 100076. [CrossRef]
30. Fung, H.W.; Choi, T.M.; Chan, C.; Ross, C.A. Psychometric properties of the pathological dissociation measures among Chinese
research participants—A study using online methods. J. Evid.-Inf. Soc. Work 2018, 15, 371–384. [CrossRef]
31. Ross, C.A.; Browning, E. The Self-Report Dissociative Disorders Interview Schedule: A preliminary report. J. Trauma Dissociation
2017, 18, 31–37. [CrossRef]
32. Fung, H.W.; Chan, C.; Lee, C.Y.; Yau, C.K.M.; Chung, H.M.; Ross, C.A. Validity of a web-based measure of borderline personality
disorder: A preliminary study. J. Evid.-Based Soc. Work 2020, 17, 443–456. [CrossRef] [PubMed]
33. Haddock, G.; McCarron, J.; Tarrier, N.; Faragher, E. Scales to measure dimensions of hallucinations and delusions: The psychotic
symptom rating scales (PSYRATS). Psychol. Med. 1999, 29, 879–889. [CrossRef] [PubMed]
34. Chien, W.T.; Lee, I.Y.-M.; Wang, L.-Q. A Chinese version of the Psychotic Symptom Rating Scales: Psychometric properties in
recent-onset and chronic psychosis. Neuropsychiatr. Dis. Treat. 2017, 13, 745. [CrossRef] [PubMed]
35. Koo, T.K.; Li, M.Y. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J. Chiropr. Med.
2016, 15, 155–163. [CrossRef]
36. Demetriou, C.; Ozer, B.; Essau, C. Self-report questionnaires. Encycl. Clin. Psychol. 2015, 1–6. [CrossRef]
37. Bernardi, R.A.; Nash, J. The importance and efficacy of controlling for social desirability response bias. Ethics Behav. 2023, 33,
413–429. [CrossRef]

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