Translation and validation of the Arabic version of the osteoarthritis quality of life questionnaire (OAQoL) in Saudi patients with osteoarthritis

Osteoarthritis (OA) is a debilitating multifactorial degenerative rheumatic disease, and one of the leading causes of functional limitations and morbidity worldwide [1]. Progressive degeneration of joints results in physical disability affecting 250 million individuals around the globe [2]. It has been estimated that 9.6% of men and 18% of women over 60 years of age suffer from symptomatic OA [3]. It has been reported that people with OA of the knees contribute to the 3.8% prevalence of symptomatic OA worldwide [4]. The prevalence of OA in the Arab world is significantly high; contributing to 53.3% of men and 60.9% of women between 30 and 93 years of age suffering from radiographically confirmed symptomatic knee OA in the Middle East [5]. The prevalence of OA in Saudi Arabia is 30.8% and 60.6% in people aged 46–55 years and 66–75 years [6].

Pain and disability in patients with OA limit their daily activities and significantly affect their quality of life (QoL) and socioeconomic status [7]. The ultimate goal of medical practice is to maintain health related quality of life. In order to assess the quality of life the practitioner needs to ask the patients questions about the physical, mental, and psychosocial aspects of the disease [8]. Quality of life instruments or questionnaires are developed to reduce bias among practitioners. Therefore, a variety of assessment questionnaires or tools is used to determine pain, disability, and QoL among patients with OA [5]. For example, the osteoarthritis quality of life scale (OAQoL), the 36-item short form survey (SF-36), the EuroQoL instrument (EQ-5D), the knee injury and osteoarthritis outcome score (KOOS), the World Health Organization quality of life (WHOQOL-100), the Japanese knee osteoarthritis measure (JKOM), and the arthritis impact measurement scales (AIMS) are used to assess the quality of life of patients suffering from OA [3, 9‐14]. The OAQoL is one of the important tools used to assess the overall impact of OA and its treatment on patients’ quality of life [3]. The OAQoL was developed in English in the United Kingdom (UK), and consists of 22 items to measure the QoL specific to OA [15]. The OAQoL assessment tool helps assess the needs of patients with OA in terms of cognition, esteem, fulfilment, safety, security, belongingness, love, and physical strength [15]. It has good psychometric qualities and is validated for the assessment of OA involving the upper and lower limbs, as well as their combination [3]. It is a common, clear, and easy assessment tool to use for outdoor patients [16]. Due to its excellent internal consistency and construct validity the English version of the OAQoL has been translated and validated in several languages in order to assess the need-based QoL among patients suffering from OA in various regions of the world [3].

Cross-cultural adaptation of an assessment tool may face problems of linguistic and conceptual equivalence. Some phrases may be recognized differently in different languages. Cross-cultural translation and validation of health-related assessment tools therefore involves translators and bilingual authors [17]. Some studies have used dual panel methodology during the cross-cultural translation and validation of the OAQoL where two panels are conducted—a bilingual panel to translate the questionnaire and a lay panel to assess the comprehension of the language [16, 18]. Having a bilingual panel expert is recommended by the World Health Organization (WHO) in order to identify and resolve any inadequate concepts, expressions, or discrepancies found between the two versions of the questionnaire or tool [19]. The purpose of using a bilingual panel is to produce a questionnaire in another language where the questions are understood in the same way in each language. However, consistency and reproducibility is assessed later to validate the new version.

The OAQoL questionnaire has been translated and validated in Portuguese, German, Hungarian, Spanish, French, Italian, and Turkish [3, 16, 20]. Despite high prevalence of OA in Arabic countries an Arabic version of the OAQoL questionnaire was not available to validate this useful tool to assess the quality of Arabic patients suffering from OA. The English version of the OAQoL questionnaire was therefore translated to Arabic by a bilingual panel in order to determine its validity in the Arabic population suffering from OA. This study is a useful addition to literature in terms of a simple and true patient-based conceptual tool for clinicians working in Arabic areas where they can assess OA patients with ease.

52.5% of the 59 participants in this study were men and 47.5% were women. Most of the participants were middle-aged and older adults—66.1% of them were between the age of 41 and 60. The specific demographic details of patients are delineated in Table 1. A full review of all the responses of the OAQoL can be found in Table 2.

Three interviewers conducted the CDIs for all 59 participants—the mean duration of the interviews was 11.3 min. Two main themes arose from the grounded theory analysis performed on the qualitative data transcribed by the interviewers. Firstly, 17 of the 59 participants opined that the questionnaire was too long. 8 participants suggested that questions could be combined to generate a more succinct questionnaire. Secondly, most of the questions were understood as intended. The feedback collated from participants showed that only 1 out of 22 questionnaires was frequently misinterpreted. The question which was frequently misinterpreted was ‘I feel slowed down’. 13 of the 59 participants interpreted this as slowing down of the pace of life, rather than slowing of movement or ambulation. After the 13th participant articulated their opinions of this question, it was adapted in consultation with the original bilingual panel convened for the translation of the OAQOL as well as both the English translators. This issue did not recur after the adaptation of this question for the subsequent interviews. Cronbach’s Alpha was used to measure the internal consistency of the questionnaire. Internal consistency refers to the degree to which all 22 items in the OAQoL measure the same concept/construct, and is therefore linked to the interrelatedness of the items. Cronbach’s Alpha was determined to be 0.93, indicating that all 22 items in the OAQoL were significantly interrelated. The derivation of Cronbach’s Alpha for all items can be found in Table 3.

This study describes the translation and validation of the OAQoL with excellent internal consistency and reliability in the Arabic language in order to assess the quality of life of patients with OA living in Saudi Arabia. The bilingual panel and English-speaking translators produced a well regulated questionnaire which was well understood by the patients during cognitive debriefing interviews (CDIs). However, during the interview the participants complained that the questionnaire was long. Cronbach’s Alpha produced acceptable internal consistency of the Arabic form of the questionnaire. During the production of the Arabic version the conceptual equivalence was adapted instead of linguistic equality so that questions included in the questionnaire could be delineated in the Arabic language in the same way as in the English language.

Gomes et al. [16] translated and validated the OAQoL questionnaire in Portuguese with the Cronbach’s Alpha score of 0.87 for internal consistency. They also tested and retested the reliability of the questionnaire through CDIs and the Spearman’s rank correlation coefficient. In this study the Cronbach’s Alpha score was 0.93 which indicates excellent internal consistency of the Arabic version of the OAQoL questionnaire. It demonstrates that this study produced a more consistent and reliable Arabic version of the OAQoL compared to the Portuguese version. Differences in the Alpha score can be statistically attributed to interitem covariances or interrelatedness of the items [21]. Wilburn et al. [3] translated, debriefed, and validated the OAQoL questionnaire in German, Hungarian, Italian, Spanish, and Turkish with the Cronbach’s Alpha score ranging between 0.94 and 0.97 and the test–retest reliability (Spearman’s rank correlation) being 0.87 to 0.98. Similarly, Couraud et al. [20] translated, debriefed, and validated the OAQoL questionnaire in French with the Cronbach’s Alpha at 0.91 and the test–retest reliability at 0.93. This study has therefore produced an excellent, reliable, and valid Arabian version of the OAQoL questionnaire.

The translated Arabic version of the OAQoL questionnaire used in this study is a reliable and consistent tool that showed good comprehensibility and internal consistency. However, the study focused on the Cronbach’s alpha for the new Arabic version of the OAQoL which offered a reliable measure of quality of life of patients with OA. In this context other psychometric properties need to be evaluated to strengthen the new version of the questionnaire. The new version can be considered to assess patients with OA in a routine clinical setup as well as to conduct OA-related research among the Saudi population. This is a pilot study and with the help of more multicenter robust studies clinicians working in Arabic countries like Saudi Arabia may be equipped with an advanced tool to determine the quality of life of patients suffering from OA as well as to investigate the impact of interventions.