|Ahead of print publication
Translation and validation of Gujarati version of Indian HAQ in RA patients
Jaspreet Kaur Kang1, Neeta J Vyas2
1 PhD Scholar, Gujarat University; Principal, Mahatma Gandhi Physiotherapy College, Ahmedabad, Gujarat, India
2 PhD Guide and Emeritus Professor, Ahmedabad Institute of Medical Sciences (AIMS), Ahmedabad, Gujarat, India
|Date of Submission||28-Sep-2021|
|Date of Acceptance||05-Jan-2022|
|Date of Web Publication||01-Jun-2022|
Jaspreet Kaur Kang,
509/2, Sector 6-B, Gandhinagar - 382 006, Gujarat
Source of Support: None, Conflict of Interest: None
Background: Routine assessments of disease activity and functional status play a key part in ensuring a high-quality rheumatologic care. The most widely used, Health Assessment Questionnaire (HAQ), has become a standard outcome measure of physical function in clinical studies.
Aims and Objectives: The study aimed to translate the English version of Indian Version of Health Assessment Questionnaire into Gujarati language and validate the translated Gujarati version of the scale.
Materials and Methods: The English version of HAQ was translated into Gujarati language using the forward-translations and back-translation method. The translated questionnaire was administered to a sample of 65 outpatients on routine follow up visit and one week later with rheumatoid arthritis (mean age) to test for content validity and reliability.
Results: Internal consistency of each item was evaluated by Cronbach's alpha and the Construct validity was evaluated by determining Spearman's correlation between the Gujarati Indian HAQ score and disease activity variables. Reliability testing showed an intraclass coefficient for HAQ of 0. 848. The internal consistency was acceptable with a Cronbach's alpha of 0.91 and indicated adequate construct validity.
Conclusion: Hence it is suggestive that the Gujarati version of Indian HAQ is a reliable and valid tool for evaluation of the functional status in rheumatoid patients.
Keywords: Indian Health Assessment Questionnaire, rheumatoid arthritis, reliability, validity
| Introduction|| |
Rheumatoid arthritis (RA) is a chronic inflammatory disease that causes pain and swelling of the joints, with disability rates up to 50% and having major, diverse effects on patients' health-related quality of life (QOL) affecting both physical and mental well-being which led to the development of various health-related QOL instruments for the assessment substantial functional limitation associated with RA. Consequently, a number of functional disability and health-related QOL measures have been developed for measurement standardization in clinical practice and trials. Health Assessment Questionnaire (HAQ) which was originally published in 1980 is the most widely accepted patient-related instrument for RA measuring functional disability through questions regarding upper extremity fine movements and lower extremity locomotor activities.
Since then, HAQ has been modified and translated into various languages across the world. It has also been validated cross-culturally and adapted with various different lifestyles. The Indian adaptation was obtained by modification of the MDHAQ published by Pincus and Sokka. The Indian HAQ comprised 12 questions (nine basic and three advanced ADL, on the standard HAQ format) relevant to the Indian population. The authors also conducted a Hindi translation and it was found to be identical to the English version.
India is a diverse land with various cultural background and languages, so the need was to translate this Indian version for non-English and non-Hindi speaking population. This study aims to evaluate the reliability and validity of Gujarati version of Indian HAQ in Gujarati-speaking patients with RA.
| Methodology|| |
A group of 65 patients through convenience sampling with RA diagnosed based on EULAR/ACR 2010 criteria that were more than 18 years old without any diagnosed mental illness were included in the study. During each visit, the following variables were recorded: tender joint count (TJC) and swollen joint count (SJC) according to the definition of ACR Glossary Committee, duration of morning stiffness (MS) using a Numeric Rating Scale (NRS), patient self-assessment of pain using a 10 cm horizontal visual analog scale (VAS) between 0 (no pain) and 10 (severe pain), and erythrocyte sedimentation rate (ESR) by Westergren method. Written consent was obtained from each participant and the study protocol was approved by the review board of the institute (approval No. JGPhysio/801/2015/).
Patients were given a prefinal draft of Gujarati Indian HAQ along with a visual analog score (VAS) and NRS for pain and stiffness, respectively, at the beginning of the interaction program. Moreover, for patients who could not read or were illiterate, the pro forma was explained to them and they were assisted by interviewers or accompanying literate relatives before and while filling the given questionnaire. They were scheduled to follow-up after 1 week; however, they were not informed about the retesting schedule before they visited for follow-up.
Process for the translation of questionnaire
The translation process of the Indian HAQ from the English language to the Gujarati language included the following steps: forward translation, synthesis, back translation, and final draft preparation as per the guidelines for cross-cultural adaptation of self-reported measures by Beaton et al.
Forward translation – Two translators (one with the background of medical field, namely T1 and other without background of medical field, namely T2) who knew both English and Gujarati languages were chosen to translate the questionnaire from English to the Gujarati language.
Synthesis – Both the Gujarati versions (by T1 and T2) were combined and two professionals who had knowledge of medical terminologies and who were known to both the languages (English and Gujarati) developed a synthesized version (T-12).
Back translation – The synthesised version (T-12) of the questionnaire was back translated into the English language by two independent translators (BT1 and BT2), who knew both English and Gujarati languages and had no information of the original questionnaire which was in the English language.
Expert panel – These versions (BT1 and BT2) were then sent for a comparative analysis with the original version to experts of the final steering committee of bilingual (in English and the Gujarati language) panel which consisted of all translators health experts-rheumatologists, methodologists, and research professionals with skill in questionnaire development and translation [detail in [Table 1]], who analysed the scale and then suggested it as accepted, accepted with modification or rejected. The changes were done in the translated questionnaire based on the suggestions of the expert panel.
Testing of the questionnaire – A prefinal Gujarati version of Indian HAQ [Figure 1] was given to 45 participants with RA diagnosed on the basis of the European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) 2010 criteria attending the rheumatology outpatient department by the researcher.
| Results and Analysis|| |
A total of 65 RA patients were recruited to participate after proper explanation of the study, and consent was obtained for participation. Fifteen males (23.1%) and fifty females (76.9%) females were included with a mean age of 48.4 years and a standard deviation of 11.7. Their ages ranged between 18 and 75 and their duration illness was variable ranging between 3 months and 25 years [Table 2]. Among the 65 patients, 7 patients were the ones who were either illiterate or needed assistance in reading the questionnaire.
The test–retest reliability of the Gujarati version of Indian HAQ was assessed using a two-way random effect model of intraclass correlation coefficient (ICC), and ICC values between 0.75 and 0.90 indicate good reliability and values greater than 0.90 indicate excellent reliability. Furthermore, in order to evaluate the average of the correlations between items, the internal consistency was assessed using the Cronbach's alpha coefficient equal to or greater than 0.70 which was considered satisfactory for internal consistency. The test–retest reliability was performed at a 1-week interval so that the patients do not remember the first test. Test–retest reliability of each domain and total of Gujarati Version Indian HAQ scores was acceptable. The average measure ICC of the Gujarati Indian HAQ was 0.848 (95% confidence interval 0.70–0.92). For each item, the mean and SD of test score and ICC for day 1 and day 7 are shown in [Table 3]. Internal consistency of the Gujarati Indian HAQ was satisfactory, with Cronbach's alpha of 0.910.
|Table 3: Test-retest reliability of each item of Gujarati version of Indian Health Assessment Questionnaire (n=65)|
Click here to view
The Spearman correlation coefficients for construct validity were acceptable with moderate-to-strong correlation between the translated version and other standard measures such as VAS and NRS for pain and stiffness, respectively, and for other measures of RA disease activity: TJC, SJC, and ESR. These correlation coefficients ranged from 0.30 to 0.53. The highest correlation coefficient was observed between the Gujarati Indian HAQ and pain (correlation coefficient 0.483), whereas the lowest was seen between the Gujarati Indian HAQ and ESR (correlation coefficient 0.395), as summarized in [Table 4].
|Table 4: Spearman correlation coefficient between Gujarati Version of Indian Health Assessment Questionnaire and patient-reported outcomes of rheumatoid arthritis disease activity (n=65)|
Click here to view
| Discussion|| |
This study describes translation and validation of the Indian HAQ into Gujarati according to rigorous methodological standards. Psychometric analyses of the translated version demonstrated adequate construct validity and internal consistency of the Gujarati Indian HAQ in RA patients.
The test–retest reliability of Gujarati Indian HAQ was acceptable (ICC of 0.848). The results of the study are similar to the previous studies such as Thai (0.89), Tunisian (0.84), Chinese (0.84), and Arabic (0.81) versions.
It can be observed that for most items, the mean response in the second visit was less than the first visit which could be due to any treatment changes like addition of any anti-inflammatory drugs or any advices by rheumatologist on physical activities or therapeutic modalities, as patients were selected randomly without taking into account the current disease activity.
The internal consistency of the Gujarati Indian HAQ (Cronbach alpha of 0.910.) was also comparable to the other versions like the Japanese (0.927), Thai (0.91), and Chinese (0.86) with Cronbach alpha values ranging from 0.86 to 0.95. The modified questionnaire shows a moderate correlation to disease activity parameters, namely ESR, TJC, SJC, pain (VAS), and MS (NRS). The lowest correlation coefficient was observed between the Gujarati Indian HAQ and ESR. This finding ratifies with the results obtained from other studies in different languages such as Arabic, Nepali, Persian, and Chinese, as ESR correlates better with RA disease duration, radiographic changes, and joint deformity than with functional disability.,
Moreover, the results obtained are in relevance to the original Indian version of HAQ as per the modification made into it in accordance to the Indian Public considering all the important daily regimes of people ranging from personal hygiene to activities of daily life, especially considering the major two activities that is sitting cross-legged on the floor which requires acute flexion of the knees besides abduction, flexion, and external rotation of the hip joints and squatting in the toilet.
The questionnaire is self-administered with minimal instructions and takes only about 3 min to complete, so it can be easily used for a disability evaluation in busy routine outdoor patient department (OPD) also. Even those who are unable to read can use the questionnaire with ease with the help of assistance, as the questions are basic and related to daily functional activities.
| Conclusion|| |
The study shows that the Gujarati version Indian HAQ is a reliable, sensitive, and valid instrument for measuring functional disability in RA in Gujarati population.
We would like to thank all the contributors for their kind support in developing and formulating the accurate questionnaire and valuable suggestions: Dr. Hemant Tiwari, Dr. Sonal Thareja, Dr Nandan Soni, Dr. Hetal Shukla, Dr. Ranjit Pillai, Dr. Bhumika Prajapati, Dr. Reena Kumari, and Dr. Rahul Singh.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bai B, Chen M, Fu L, Liu H, Jin L, Wei T, et al.
Quality of life and influencing factors of patients with rheumatoid arthritis in Northeast China. Health Qual Life Outcomes 2020;18:119.
Nazary-Moghadam S, Zeinalzadeh A, Salavati M, Almasi S, Negahban H. Adaptation, reliability and validity testing of a Persian version of the health assessment questionnaire-disability index in Iranian patients with rheumatoid arthritis. J Bodyw Mov Ther 2017;21:133-40.
Kumar A, Malaviya AN, Pandhi A, Singh R. Validation of an Indian version of the health assessment questionnaire in patients with rheumatoid arthritis. Rheumatology 2002;41:1457-9.
Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO 3rd
, et al.
2010 Rheumatoid arthritis classification criteria: An American College of rheumatology/European league against rheumatism collaborative initiative. Arthritis Rheum 2010;62:2569-81.
El Meidany YM, El Gaafary MM, Ahmed I. Cross-cultural adaptation and validation of an Arabic health assessment questionnaire for use in rheumatoid arthritis patients. Joint Bone Spine 2003;70:195-202.
Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976) 2000;25:3186-91.
Osiri M, Wongchinsri J, Ukritchon S, Hanvivadhanakul P, Kasitanon N, Siripaitoon B. Comprehensibility, reliability, validity, and responsiveness of the Thai version of the health assessment questionnaire in Thai patients with rheumatoid arthritis. Arthritis Res Ther 2009;11:R129.
Bejia I, Laatar A, Ben Salem K, Touzi M, Beraoui N, Zakraoui L. Validation of the Tunisian version of the health assessment questionnaire (HAQ) in rheumatoid arthritis patients. Tunis Med 2006;84:155-60.
Koh ET, Seow A, Pong LY, Koh WH, Chan L, Howe HS, et al.
Cross cultural adaptation and validation of the Chinese health assessment questionnaire for use in rheumatoid arthritis. J Rheumatol 1998;25:1705-8.
Matsuda Y, Singh G, Yamanaka H, Tanaka E, Urano W, Taniguchi A, et al.
Validation of a Japanese version of the Stanford Health Assessment Questionnaire in 3,763 patients with rheumatoid arthritis. Arthritis Rheum. 2003;49:784-8.
Sokka T. How should rheumatoid arthritis disease activity be measured today and in the future in clinical care? Rheum Dis Clin North Am 2010;36:243-57.
Pincus T, Sokka T. Quantitative measures and indices to assess rheumatoid arthritis in clinical trials and clinical care. Rheum Dis Clin North Am 2004;30:725-51.
[Table 1], [Table 2], [Table 3], [Table 4]