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Background  Rasch analysis with a focus on Differential Item Functioning (DIF) is increasingly used for examination of psychometric properties of health outcome measures. To take account of DIF in order to retain precision of measurement, split of DIF-items into separate sample specific items has become a frequently used technique. The purpose of the paper is to present and summarise recent advances of analysis of DIF in a unified methodology. In particular, the paper focuses on the use of analysis of variance (ANOVA) as a method to simultaneously detect uniform and non-uniform DIF, the need to distinguish between real and artificial DIF and the trade-off between reliability and validity. An illustrative example from health research is used to demonstrate how DIF, in this case between genders, can be identified, quantified and under specific circumstances accounted for using the Rasch model.    Methods  Rasch analyses of DIF were conducted of a composite measure of psychosomatic problems using Swedish data from the Health Behaviour in School-aged Children study for grade 9 students collected during the 1985–2014 time periods.    Results  The procedures demonstrate how DIF can be identified efficiently by ANOVA of residuals, and how the magnitude of DIF can be quantified and potentially accounted for by resolving items according to identifiable groups and using principles of test equating on the resolved items. The results of the analysis also show that the real DIF in some items does affect person measurement estimates.    Conclusions  Firstly, in order to distinguish between real and artificial DIF, the items showing DIF initially should not be resolved simultaneously but sequentially. Secondly, while resolving instead of deleting a DIF item may retain reliability, both options may affect the content validity negatively. Resolving items with DIF is not justified if the source of the DIF is relevant for the content of the variable; then resolving DIF may deteriorate the validity of the instrument. Generally, decisions on resolving items to deal with DIF should also rely on external information.

Recent advances in analysis of differential item functioning in health research using the Rasch model