We report our results in two parts. Each part presents a detailed analysis of a specific item from the SF-36 and identifies further items to which the analysis applies because of structural similarities between the items. The analyses each follow the three steps of the method outlined in Sect. 2.
Our first findings concern item 6 of the Danish SF-36 (corresponding to item 20 in the English version). The item reads: ‘Inden for de sidste 4 uger hvor meget har dit fysiske helbred eller følelsesmæssige problemer vanskeliggjort din kontakt med familie, venner, naboer eller andre?’ (Eng. ‘During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbours or groups?’). The answer options are ‘Slet ikke’, ‘Lidt, ‘Noget’, ‘En hel del’, ‘Virkelig meget’ (Eng. ‘Not at all’, ‘A little’, ‘Some’, ‘Quite a bit’, ‘Very much’). These options are ordered so that the fifth option is compatible with all three preceding options, the fourth is compatible with the two preceding options, the third is compatible with the second, fourth and fifth options, and the second is compatible with the third, fourth and fifth options. So, unless the first answer option, ‘Slet ikke’, is true of the participant, more than one of the remaining answers will be true of her. Lexically, the pronoun ‘Noget’ denotes any value on the positive range of the degree scale and entails only ‘Lidt’ among the alternative answer options. The pronoun ‘Lidt’ entails ‘Noget’ but does not entail any other answer option, while the lexicalized meaning of ‘En hel del’ semantically entails the two preceding options but not ‘Virkelig meget’. Furthermore, because of its compositional lexical meaning, ‘Virkelig meget’ entails the three preceding options by denoting the upper end of a scale measuring amounts.
The fact that several answer options are compatible and available, however, does not entail that the choice between them is unclear. Pragmatic dynamics may supplement the participant’s interpretation of the answer options. In this case, such dynamics are likely to arise from the options available to the participant. Because of their links to scales, the answer options give rise to scalar implicatures [15, 16, 36], which aid the interpretation of the logically compatible answer options. To be as informative as the questionnaire requires, the participant has to pick the most informative option she can without violating the Quality maxims. Thus, if she is in a position to answer ‘Virkelig meget’, opting for another answer will violate Quantity 1 by being less informative than the questionnaire allows. If Quality permits her to answer ‘En hel del’ but not ‘Virkelig meget’, then answering ‘Noget’ or ‘Lidt’ will be less informative than required by CP.
In addition, because ‘Noget’ is logically compatible with the whole range of positive degrees, ‘Noget’ will be interpreted as communicating that ‘Lidt’, ‘En hel del’ and ‘Virkelig meget’ all misrepresent the participant’s judgement. This may represent the participant’s inability to determine the answer to the item by anything more precise than an entirely unspecified non-zero value. Or it may indicate that the answer options ‘Lidt’, ‘En hel del’ and ‘Virkelig meget’ are not suitable to represent the degree to which contact has been made difficult for the participant by her health issues. Of these two possibilities, ‘Noget’ will likely be interpreted as communicating the latter, given how ‘Lidt’ and ‘En hel del’ are interpreted. ‘Lidt’ has a lexicalized link to a scale that orders a continuum of amounts with a zero amount as the upper bound and an infinitely little, non-zero amount as the maximum value. This connection to a scale of littleness gives ‘Lidt’ the interpretation ‘(at least as little as) Lidt’. Correspondingly, a lexically defined relation to a reverse scale on the same continuum, going towards an infinitely great amount, gives ‘En hel del’ the interpretation ‘(as least as much as) En hel del’ and ‘Virkelig meget’ the interpretation ‘(at least as much as) Virkelig meget’. Consequently, the answer option ‘Noget’ will tend to be interpreted as representing amounts that are not among the values ‘(at least as little as/no more than) Lidt’ and ‘(at least as much as/no less than) En hel del’.
With respect to the first question of item 6 in the Danish SF-36, the pragmatic dynamics hence seem benign with respect to the aim of interpreting answers as they are intended by participants. There is a caveat, however. Because Lidt’, ‘En hel del’ and ‘Virkelig meget’ are context-sensitive expressions, which depend on a speaker’s context-of-utterance to determine their values [28–30], the distances between them remain less than entirely clear, as does their comparative span. It is unclear, for example, how the length of a segment ranging from ‘Lidt’ to zero (the upper bound for maximal littleness) compares to the length of the segment corresponding to more than ‘Lidt’ but less than ‘En hel del’. This, in turn, leaves it unclear whether the different answer options provide equally accurate means of representing judgements along the continuum of amounts. Furthermore, because their values shift between different contexts, the precise scalar degree they represent might be different for different participants on different occasions. Although their lexically encoded meanings fix the ordering of ‘Lidt’, ‘En hel del’ and ‘Virkelig meget’, the encoded meanings fall short of determining which specific scale segments they each denote.
Owing to structural similarities, these results carry over to the pragmatic dynamics influencing the interpretation of answer options. The third question under item 6 (corresponding to item 22 in the English version) has exactly the same answer options as the first question. There are also sufficient structural similarities to conclude that the pragmatic dynamics work similarly for items 9a–i (items 23–31 in the English version) and 10 (item 32 in the English version), where the answer options are ‘Hele tiden’ (Eng. ‘All of the time’), ‘Det meste af tiden’ (Eng. ‘Most of the time’), ‘En hel del af tiden’ (Eng. ‘A good bit of the time’), ‘Noget af tiden’ (Eng. ‘Some of the time’), ‘Lidt af tiden’ (Eng. ‘A little of the time’) and ‘På intet tidspunkt’ (Eng. ‘At no time’). For these items, we would also expect the pragmatic dynamics to be benign with respect to ordering but problematic with respect to how the segments of the answer scale are divided because the terms of the answer options have context-sensitive semantic values.
The items 11a–d (items 33–36 in the English version) call for a different analysis. To examine their pragmatic dynamics, we consider 11b (item 34). In this item, the participant is asked to respond to the statement ‘Jeg er lige så rask som enhver anden, jeg kender’ (Eng. ‘I am as healthy as anybody I know’) with one of the following five answer options: ‘Helt rigtigt’ (Eng. ‘Completely correct’), ‘Overvejende rigtigt’ (Eng. ‘Predominantly correct’), ‘Ved ikke’ (Eng. ‘Don’t know’), ‘Overvejende forkert’ (Eng. ‘Predominantly wrong’) and ‘Helt forkert’ (Eng. ‘Completely wrong’). Here ‘Helt rigtigt’ entails ‘Overvejende rigtigt’, while ‘Overvejende rigtigt’ is compatible with ‘Helt rigtigt’ but does not entail it. Both ‘Helt rigtigt’ and ‘Overvejende rigtigt’ are incompatible with both ‘Helt forkert’ and ‘Overvejende forkert’. Similarly, ‘Helt forkert’ entails ‘Overvejende forkert’, while ’Overvejende forkert’ is compatible with but does not entail ‘Helt forkert’. ‘Ved ikke’ (Eng. ‘Don’t know’) is compatible with all of the other four answer options, entails none and is entailed by none. That a participant does not know whether her health is excellent does not entail that it is not, nor that it is, because the factors that determine one’s health are fairly (albeit, perhaps not entirely) independent of how one makes assessments about one’s health. There is no connection between a person’s health and their knowledge of their health that ensures that a respondent knows how healthy she is.
The relations of the answer options in item 11d to scales measuring degrees of correctness ensure that their interpretation is strongly influenced by scalar implicatures. Both Quality and Quantity contribute to the pragmatic dynamics responsible for these implicatures. Although a participant in a position to answer ‘Helt rigtigt’ without violating Quality will also be in a position to answer ‘Overvejende rigtigt’ without violating Quality, Quantity would require her to answer ‘Helt rigtigt’ for her answer to be appropriately informative. If a participant opts to answer ‘Overvejende rigtigt’, she thereby communicates that she is not in a position to answer ‘Helt rigtigt’ without violating Quality. The relations between ‘Helt forkert’ and ‘Overvejende rigtigt’ are similar. Answering ‘Overvejende rigtigt’ will implicate that the participant is not in a position to choose the answer option ‘Helt rigtigt’, whereas ‘Helt rigtigt’ will be the answer required from the participant for compliance with CP whenever a participant is in a position to answer ‘Helt rigtigt’ without violating Quality.
The interpretation of ‘Ved ikke’ (present only in items 33–36) is strongly influenced by how the other answer options are interpreted. ‘Helt rigtigt’ and ‘Overvejende rigtigt’ are related semantically to an ordinal scale that orders a continuum of degrees of correctness (assumed by the Danish questionnaire) with completely correct as the maximum value. ‘Helt forkert’ and ‘Overvejende forkert’ have a similar link to the reverse scale (i.e., the bipolar structure of a Likert scale) with completely wrong as the maximum value. ‘Overvejende rigtigt’ hence gets the interpretation ‘(at least as correct as) Overvejende rigtigt’, while ‘Overvejende forkert’ gets the interpretation ‘(at least as wrong as) Overvejende forkert’. So, the only unoccupied segment of the continuum of relative correctness/wrongness that ‘Ved ikke’ may represent is the point with no asymmetry between relative correctness and relative wrongness.
The answer ‘Ved ikke’ might also relate to different ways in which the participant fails to know any of the other answer options. Assuming the standard view that knowledge is justified, true belief that is not true merely by a fortunate coincidence [17], the most likely reasons for a respondent to judge that she does not know any answer option are that she does not believe any answer option (possibly because she is unable to adjudicate the question) or that, for each available answer option, the respondent’s evidence for the answer is insufficiently justified for her to self-ascribe knowledge that the answer is right.
The latter of these options is the more troubling because there are situations in which even a subject with good evidence for a belief might be reluctant to self-ascribe knowledge. There might be situations in which a participant believes an answer option that is favoured by her evidence but still thinks that she does not know the answer to be true because she considers her evidence insufficient for knowledge. In combination with the influence that awareness of salient error possibilities has on knowledge ascription, this has the potential to pressure some participants towards answering ‘Ved ikke’ even though their evidence favours another option. Research in experimental epistemology indicates that subjects are less inclined to self-ascribe knowledge when they become aware of ways in which their beliefs might seem true despite being false [18, 33, 35]. This tendency might affect the answers to 11d (item 36) from respondents who are aware of having an increased risk of undetected serious illness. A cancer survivor who fears an as yet undetected relapse, for example, would be likely to have this possibility in mind, and the same might apply to respondents who know themselves to be at an increased risk of developing diseases that are asymptomatic in their initial stages. Because the possibility of being ill without any indications of illness will be highly salient to respondents in these situations, well-documented patterns of knowledge ascription predict that they will have a higher inclination to answer ‘Ved ikke’ to 11d (item 36) than would other respondents.
The answer options from 11d are also used in 11a–c (items 33–35), but in two of those items – 11a (item 33) and 11c (item 35) – the above concern is mitigated by the fact that the target statement assessed by a respondent explicitly focuses on the respondent’s beliefs. In 11a, the target statement is ‘Jeg bliver nok lidt lettere syg end andre’ (Eng. ‘I seem to get sick a little easier than other people’); in 11c, the statement is ‘Jeg forventer, at mit helbred bliver dårligere’ (Eng. ‘I expect my health to get worse’). As expressed by the words ‘nok’ (Eng. ‘seem’), which indicates conjecture or estimation, and ‘forventer’, which means ‘expects’, these questions are explicitly concerned with how the respondent assesses the target statement. Assuming that a respondent has relatively direct cognitive access to her assessment of such a statement, the contents of 11a (item 33) and 11c (item 35) counteract the kind of concern related to 11d (item 36).