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Systematic Review and Appraisal of the Cross-Cultural Validity of Functional Status Assessment Measures in Rheumatoid Arthritis.

  • Author(s): Kulhawy-Wibe, Stephanie C;
  • Zell, JoAnn;
  • Michaud, Kaleb;
  • Yazdany, Jinoos;
  • Davis, Aileen M;
  • Ehrlich-Jones, Linda;
  • Thorne, J Carter;
  • Everix, Donna;
  • Cappelli, Laura C;
  • Suter, Lisa G;
  • Limanni, Alex;
  • Barber, Claire EH
  • et al.

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We conducted a systematic review and appraisal of the cross-cultural adaptation and cross-cultural validity of the Health Assessment Questionnaire (HAQ) and its derivatives, and of the more recent Patient-Reported Outcomes Measurement Information System (PROMIS) functional status assessment measures (FSAMs) in rheumatoid arthritis.


Four electronic medical databases were searched from inception until April 4, 2018 according to the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) group search strategy. Included studies were evaluated using the COSMIN tool for cross-cultural validity and were scored as excellent, good, fair, or poor.


Of 58 articles identified by our search strategy and 3 by manual search, 39 were included: 29 described the translation, cultural adaptation, or cross-cultural validity of the HAQ disability index, 8 other HAQ derivatives, and 2 PROMIS measures, representing 22 languages. Of the 39 articles reviewed, 3 examined the cross-cultural validity of translated versions. These studies were rated as follows: 2 as excellent, 3 good, 13 fair, and 21 poor. Two studies examining cross-cultural validity noted differential item functioning (DIF) between Dutch and US populations for the HAQ-II and PROMIS measures, and a third study found DIF between Turkish and UK populations on the HAQ, indicating cultural differences in questionnaire response.


This review highlights a paucity of data on the cross-cultural validity of FSAMs and the mostly poor- or fair-quality methods by which they were translated and adapted, which needs to be considered when using these measures for multinational clinical trials and for day-to-day use in clinical practice.

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