Cross-cultural adaptation and validation of an Arabic Health Assessment Questionnaire for use in rheumatoid arthritis patients

Abstract

Objective. – To test the reliability and validity of a modified and translated version of the original Health Assessment Questionnaire (HAQ) on patients with rheumatoid arthritis (RA).

Method. – A cohort of 184 RA patients from different Arabic countries (Egypt, Saudi Arabia, Sudan, Syria, Bahrain, Kuwait and Morocco) were recruited and asked to participate in the study. Two questions had been changed to suit the Arabic culture and to tackle some aspects that are commoner to be performed in the Arabic culture. After modification, translation and retranslation of the questionnaire, it was administered to the selected patients and tested for internal consistency, reliability and construct validity by correlating the yield of the questionnaire with other disease activity parameters. The questionnaire was administered again after a 1-week interval for evaluation of the reliability of this test. The modified questions were tested for their loyalty to the principal component and comparing their correlation with that of the other unchanged items.

Results. – Test-retest showed strong reliability with a high percentage of agreement and high values for Kappa. Internal consistency showed a high value for standardized alpha (Cronbach’s): 0.979 that did not show any significant change if any of the 20 items had been eliminated. The modified questionnaire had shown a strong validity when correlating its results with other disease activity parameters. This correlation was the strongest with tender joint count (TJC), Ritchie articular index (RAI), morning stiffness (MS) and visual analogue scale (VAS) and the least (but still significant) with rheumatoid factor (RF).

Conclusion. – The Arabic HAQ is a reliable and valid instrument that can be self-administered to Arabic RA patients to evaluate their functional disability. Its measurement properties were comparable to versions in other languages.

Introduction

The increasing interest in using health related quality of life outcome measures in rheumatoid arthritis (RA) has been made possible with the development of measures specific to this condition. In fact, assessment of measures of physical function is essential in RA patients to evaluate the course of the disease and assess treatment effects [1]. As the American College of Rheumatology (ACR) introduced its preliminary definition of improvement in RA, patients’ assessment of physical function has been considered one of the determinants of disease activity measures [2]. A number of instruments have been developed to measure functional disability, ranging from physical assessment by trained assessors, to self-administered questionnaires [1], [3]. Some of these questionnaires such as the Health Assessment Questionnaire (HAQ) [4] and its modified version [5], the Arthritis Impact Measurement Scales (AIMS) [6], AIMS2 [7] and their shortened versions [8], [9] and the functional status index [10], are specifically designed for patients with RA. Among these, HAQ is probably the most widely used. Its advantages lie in ease of use, being short and having excellent reliability and validity. In contrast to other instruments mentioned above, which can be considered as multidimensional health status measures, HAQ has been reported as the best tool targeting functional disability [11]. Moreover, the validity and reliability of the HAQ have been confirmed in several ethnic groups. Translated versions of HAQ in Spanish, Portuguese, Swedish, French, Italian, Korean and Chinese are available [11], [12], [13], [14], [15], [16], [17], [18]. The only published Arabic study that introduced an Arabic version of HAQ was a mere translation of the questionnaire from English to Arabic without consideration of the Arabic culture [19]. The aim of our study was to assess the cultural appropriateness of HAQ for Arabs, translate the questionnaire and study its psychometric properties for research and clinical application.